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Health IT and Patient Safety: Building Safer Systems for Bet

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Esther Felicien

on 31 August 2014

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Transcript of Health IT and Patient Safety: Building Safer Systems for Bet


Although the 1999 IOM report
To err is human
created a whirlwind of events that surrounded measures to increase patient safety and enhance quality care, there is much controversy on what improvement in safety have actually occurred.
What is known is that quality improvement is occurring at a sluggish pace and that patients continue to experience high rates of safety problems during hospital stays.
Post 1999 IOM report
Much of the focus was on quality, with thoughts that increase in quality would drastically increase safety.

Health IT has been and continues to be noted as a critical tool to measure and improve patient safety.

Yet, despite this possibility, the widespread adoption and safe use of heath IT tools is relatively slow with technical and organizational limitations existing.
Advantages of Health IT
Clinicians expect health IT to support delivery of high quality care in several ways including:
storing data
providing CDS
facilitating communication
engaging patients and reducing medical errors.

Administrators expect HIT to:
Reduce cost through increased efficiency
Increase payment through charge capture

1. Health IT designed to maximize administrative and economic benefits may create new paths to failure.

2. Health IT reports show distraction or mis-communication, may cause harm if it is poorly designed, implemented or applied.

3. Examples of health IT induced harm that can result in serious injury and death include dosing errors, failing to detect fatal illnesses, and delaying treatment due to poor human- computer interaction or loss of data.

Giving the new and large investment being made in health IT, it is imperative that health IT maximize patient safety while minimizing harm

ONC’s health IT policy committee in 2010 held a hearing on patient safety and recommended a formal study to thoroughly evaluate health IT patient safety concerns and to recommend additional actions and strategies to address these concerns.

Health IT and Patient Safety:

Building Safer Systems for Better Care
Committee on Patient Safety and Health Information Technology;
Institute of
Medicine Report

GAIL L. WARDEN (Chair), President Emeritus, Henry Ford Health
System, Detroit, MI
JAMES P. BAGIAN, Director, Center for Health Engineering and
Patient Safety, Chief Patient Safety and Systems Innovation Officer,
Department of Industrial and Operations Engineering, University of
Michigan, Ann Arbor, MI
RICHARD BARON,1 Professor and CEO, Greenhouse Internists, PC,
Philadelphia, PA
DAVID W. BATES, Chief, General Medicine Division, Brigham and
Women’s Hospital, Boston, MA
DEDRA CANTRELL, Chief Information Officer, Emory Healthcare, Inc.,
Atlanta, GA

DAVID C. CLASSEN, Associate Professor of Medicine, University
of Utah, Senior Vice President and Chief Medical Officer, CSC,
Salt Lake City, UT
RICHARD I. COOK, Associate Professor of Anesthesia and Critical
Care, University of Chicago, IL
DON E. DETMER, Medical Director, Division of Advocacy and
Health Policy, American College of Surgeons, Washington, DC, and
Professor Emeritus and Professor of Medical Education, University of
Virginia School of Medicine, Charlottesville, VA
MEGHAN DIERKS, Assistant Professor at Harvard Medical School,
Director, Clinical Systems Analysis at Beth Israel Deaconess Medical
Center, Brookline, MA
TERHILDA GARRIDO, Vice President, Health IT Transformation and
Analytics, Kaiser Permanente, Oakland, CA
ASHISH JHA, Associate Professor of Health Policy and Management,
Department of Health Policy and Management, Harvard School of
Public Health, Boston, MA
MICHAEL LESK, Professor, Rutgers University, New Brunswick, NJ
ARTHUR A. LEVIN, Director, Center for Medical Consumers,
New York, NY

JOHN R. LUMPKIN, Senior Vice President and Director, Health Care
Group, Robert Wood Johnson Foundation, Princeton, NJ
VIMLA L. PATEL, Senior Research Scientist, New York Academy
of Medicine, and Adjunct Professor of Biomedical Informatics,
Columbia University, New York, NY
PHILIP SCHNEIDER, Clinical Professor and Associate Dean, University
of Arizona College of Pharmacy, Phoenix, AZ
CHRISTINE A. SINSKY, Physician, Department of Internal Medicine,
Medical Associates Clinic and Health Plans, Dubuque, IA
PAUL C. TANG,2 Vice President, Chief Innovation and Technology
Officer, Palo Alto Medical Foundation and Consulting Associate
Professor of Medicine, Stanford University, Stanford, CA
IOM Study Staff
SAMANTHA M. CHAO, Study Director
PAMELA CIPRIANO, Distinguished Nurse Scholar-in-Residence
HERBERT S. LIN, Chief Scientist, Computer Sciences and
Telecommunications Board
JENSEN N. JOSE, Research Associate
JOI D. WASHINGTON, Research Assistant
ROGER C. HERDMAN, Director, Board on Health Care Services
Laura Mitchell Esther Felicien
The committee was task with
Summarizing existing knowledge on the effects of health IT on patient safety

Make recommendations to HHS regarding specific actions that federal agencies should take to maximize the safety of health IT assisted care

Make recommendations concerning how private actors can promote the safety of health IT assisted care and how the federal government can assist private actors in this regard


Preliminary Analysis
A. Literature was searched
B. Reviewed
C. Analyzed
D. Stored into Categories
E. Summarized into a table

A. Literature Search Strategy
I) Four databases: 2,868 initial results of articles, books, and other literature
Web of Science
II) Each database search used terms and Medical Subject Headings related to patient safety and medical informatics.
A) Patient Safety
accidental harm
adverse events
diagnostic errors
errors of omission or commission
medication errors

B) Medical Informatics
human factors
system design
system analysis
user-computer interface

III) Strategy parameters
Human subjects
English language
Results published between January
2005-November 2010
Hand searches through references with relevant searches included

IV) Primary and secondary research
suggested by the public and the committee
• Meta-analysis
• Controlled trials

B. Reviewed
i) Titles and abstracts of the produced articles were rigorously evaluated
to paired reviewers to determine the inclusion criteria for quality and relevance.
ii) Articles independently assigned to one of three categories: Category 1 being most
relevant and Category 3 being the least relevant.
iii) Post categorizing, evaluations were compared, and disagreements resolved through
discussion. Full texts of articles in Category 1 were retrieved, evaluated,
and if needed, re categorized.

C. Analyzed and Categorized
i) Category 1: Literature examining how health IT affects patient safety
1a: Systematic reviews
1b: Experimental studies
1c: Observational studies
ii) Category 2: Literature describing efforts to improve quality of health care through implementation
of system design, systems analysis, usability, user-computer interface, or human factors.
iii) Category 3: Studies not related to patient safety and health IT.

D. Summary and Results
i) Category 1: 128 articles yielded
Placed into two tables that were organized by the type of health IT components.
Table 1-systematic reviews summarized
Table 2- experimental and observational

Literature found significant improvements in safety in health care institutions with a strong health IT program.
Medication Safety

Some studies have found no effect in improvements of patient safety beyond medication safety and across the health care system.
Health IT associated harm has been reported.
Dosing errors
Failing to detect fatal illnesses
Delaying treatment due to poor human-computer interactions or loss of data.
Health IT-induced medical error or harm, can result in serious injuries and death as shown by a MSNBC report on medical error tragedies.

Studies regarding the impact of health IT on patient safety have been narrowly focused on a few specific aspects of care and more on quality and processes of care.

Much of this evidence suggests that IT can be helpful in improving patient safety.

Several studies offer strong evidence that computerization of prescribing can greatly improve patient safety.

Studies outside of medication safety having an impact on Health-IT was weaker.

Most recent data suggested that health IT can introduce new patient safety challenges into the health care system. However these studies were unable to accurately quantify the number of people harmed by health IT, which makes it difficult for the committee to understand the tradeoff between the potential safety benefits and harm caused by health IT.

IOM Report Summary
Building Safer Systems for Better Care.
IOM ultimate goal for health IT existence is to “maximize patient safety while minimizing harm”

Member of the IOM report agrees that:
The current state of safety and health IT is not acceptable and specific actions are required to improve the safety of health IT.

The findings are categorize from a socio-technical system.

IOM report adopts a socio-technical perspective in regard to health IT safety. The socio-technical perspective acknowledges that safety emerges from the interaction among various factors .

To improve safety, health IT needs to optimize the interaction between people, technology, and the rest of the socio-technical system by engaging end users in design, deployment, and integration of the software product into the workflows (IOM, 2012).

5 systemic needs health care providers must be satisfied to maximize safe performance

1) Limit the discretion of workers
2) Reduce worker autonomy
3) Transition from a craftsmanship mindset to that of equivalent actors
4) Develop system-level (senior leadership) arbitration to optimize safety strategies
5) Strive for simplification


The life cycle of health IT in regards to a safer system is dependent:
1. Design and development of health IT.
2. Implementation and use of health IT for the end user.

1. System Design
A. Design and developing the key features of Health IT between users and vendors across the continuum will improve patient safety and not cause harm or increase risks.

B. Key Features:
I) Workflow
II) Usability
III) Balanced customization
IV) Interoperability

I) Workflow
HIT implementation changes clinical workflows in unanticipated ways; these may be detrimental to patient safety.
Inflexible order sequence may increase the cognitive workload of the healthcare professional while he or she hold important orders in mind while navigating through mandatory screens.
The practice of “paste forward” or “copy forward” does not enhance an efficient clinician workflow.
Poor workflow over times increases the healthcare provider of making errors.


• Usability as a key driver of safety and that poor usability is one of the single greatest threats to patient safety.

• Usability guidelines and principles focused on improving safety need to be put into practice.

• Healthcare professional/provider should be assessed for the best style to interact with the computer system. For example, form fill-in, command language, menu selection, or moving objects on a screen with direct manipulation.

• The National Institute of Standards and Technology (NIST) develops guidelines and standards for usability design and evaluation.

• Rapid Usability Assessment by National Center for Cognitive Informatics and Decision Making in Healthcare (NCCD) to assess the usability of EHRs on specific meaningful use objectives and to provide feedback to vendors to help improve their systems (IOM, 2012).

• From the NCCD came TURF: task, user, representation, and function. This framework predicts usability differences across EHR systems

Interoperability HIT:

• Must extend throughout the continuum of care to include pharmacies, laboratories, ambulatory, acute, and long-term care settings.

• Common nomenclatures must be used to include encoding formats and presentations.

• Avoid copying or transcribing by hand to prevent lost data.

• Accept “plug- ins” so the end user have the ability to select modules from multiple vendors that may perform a specific function more safely.

• Consistency in the display of similar information so the end user will have the same interpretation.

• Software components that will exchange the physical data stream and not force the users to reenter data manually.

Implementation and Post deployment Activities:

Greatest threats to safety is during initial implementation
Problems that are most likely to have safety risks will appear in the operational environment of the implementation phase.

Vendor Implementation Activities
i) Software Implementation Activity.
II) Maintenance Activity
Provide healthcare professionals advanced notice to minimize disruption of care when taking software offline for maintenance.

• Establish workflow procedures for scheduled and/or unexpected downtime.
III) Upgrade Activity

Health IT User Activities- Clinical Implementation
I Planning
II) Deployment
Testing locally to verify safety, interoperability, security, and effectiveness.
Establish mechanisms and metrics to identify, escalate, and re-mediate patient safety issues.

III) Stabilization
• Steps to resolve potential hazards.
• Improve patient safety by utilizing data generated by the health IT system.

IV) Optimization
• Engage clinical decision support.
• Readdress changes needed for workflow improvements.

V) Transformation
Continue to measure the improved clinical and efficiency outcomes.

System Safety for Small Hospitals and Practices

Ninety-three percent of all primary care physicians work in organizations of 10 physicians or fewer; of those, about half practice in organizations with 1 to 2 physicians.

*Limited expertise in health IT implementation, workflow redesign, and training

*Tend to lack champions and administrative support to vision how health IT fits into the overall picture of health care delivery.

*Fail to recognize and abate risks even after sentinel events.

*Tend to fall behind in health IT implementation compared to large integrated delivery or hospital-based system.

Safety of Patients’ and Families’ Use of Health IT
Patient-centered care is one of the six aims of IOM’s quality health care. Health information technology can help patients become more involved in their own care like managing dietary logs and calorie counts.

The impact of safety need to be examined.
The biggest growth of consumer health IT in recent years is for Personal Health Records (PHRs)

Personal Health Records

A. Intergrated PHR’s
I) Patients add supplemental data regarding their conditions through a secure portal online.
11)Patients have the opportunity to amend data and track progress on chronic health issues or/and interact with their care team.
III) It is a difficult for some EHRs’ to build this type of PHR, but the few who does this can serve as models.
IV) Does not require patients to actively manage or maintain their data, but still have access to it.

B. Freestanding PHR’s
I) Not linked to an PHR. For example: Microsoft Health Vault.
II) Many allow individuals to access data from different providers’ EHRs.
III) “Blue button” concept help consumers download electronic copies of health records to a location of their choice. MyHealthVet and MyMedicare also allows this capabilities. (IOM, 2012).

There is an urgent need for more research with consumer use of health IT regarding safety.

Current State of Work
Health IT and Patient

Patient Safety
The IOM report reviewed the different components of the Electronic Health Record systems regarding the impact on patient safety with Health IT.
Electronic Health Records
Clinical Decision Support
Bar Coding
To improve safety, health IT needs to optimize the interaction between
people, technology, and the rest of the sociotechnical system. Socio technical
theory, advocates for direct involvement of end
users in system design. It shifts the paradigm for software development
from technical development done in isolation by software and systems
engineers, to a process that is inclusive and iterative, engaging end users in
design, deployment, and integration of the software product into workflow
to enhance satisfaction and effectiveness

HHS should support a research program to study patient and the use of information technology with a goal of addressing issues raised. To create a shared learning environment , research should combine efforts from several organizations such as the Department of Defense, Department of Veteran Affairs, National Institute for Standards and Technology and the National Science Foundation.
Safety is a characteristic of a system-

The End Result will be an increased quality, Safer, and Cost Efficient Health Care System
It is the product of its constituent components and
their interactions.

Medication errors rates fell.
Shorter order turnaround times.
Large increases in legible orders.
Higher percentage of patients obtained their treatment goals.
Best impact when designed for specific needs of hospital, workflow, and providers.

Fragmented displays or ineffective interface.
Incompatible orders
Limited data on harm due to limited disclosures of health IT related events and practices.
Inflexible ordering formats generating
wrong orders.
Implementation has been reported to increase providers' perception of safety.
One study found that electronic vital sign documentation can reduce medical error in half.
Specifically designed order set increased efficiency and workflow.
EHR's databases have the ability to be data-mined to study the occurance of harm.
Have tools to update the problem and medication list.
Additional research needs to be done on how EHR designs affect different workflow and provider's needs.
Data extracted should be utilized more
to improve safety.
Point of Care monitoring of patient conditions, prescriptions, and treatment using evidence- based suggestions to health professionals.

Medication safety improved practitioner performance and time to therapeutic stabilization.
Various forms of alerts that appear when provider's assess patient's EHRs or enter orders.
Alerts that are implemented correctly, can/have improved patient safety and workflow.
Improperly designed system for CDS may be ignored or rejected by end users.
Significant reductions in relative risk of medication errors, including transcription, dispensing and administration errors.
A lot of workarounds noted that could jeopardize patient's care. (Patient bar codes not on pt).
Clinicians violate safe procedures and practices by scanning medications and patient identification without visually checking five rights.
Clinicians known to scan all the orders and medications of multiple patients at once.
Health IT safety for Nursing.
Health IT Safety For

It is important to include Nurses in the design of Health IT.
Nurses are the main end users with majority of health IT.

Nurses interactions with technology and each other in technology are very likely to affect clinical outcomes.

Appointing a chief medical or nursing information officer as a bridge between IT staff and clinicians is vital to the success of Health IT.

It is critical for nurses to understand health IT and how to use technology for safe delivery of health care.
Literature Review: Impact of Health IT on Patient

IOM Report Clinical Content focus:

• IT should reflect the organizational goals.

• Maximize the usage of expensive computers and therapeutic machines while minimizing the costs.

• Promoting safety of patient care while maximizing effectiveness and efficiency.

• Eliminate the workarounds that may undermine patient safety.

• Develop formal policies to enhance the nurse’s workflow.

• Go beyond the better training of the user and review the underlying operation of why something went wrong, or might happen negatively.

Clinician Training:

• Coach technology developers to work with clinicians to redesign workflow, manage and support implementation.

• Nurses must learn the full functionality of systems.

• Nurses need to learn how to incorporate specific Health IT products into their daily workflow.

• Train nurses to recognize that health IT can improve quality of care, as well as of its potential to negatively impact patient safety if used inappropriately.

• Increase programs to focus on training health professionals to use health-IT.

Support for Clinician Training:
Encourage clinical training with formal education with residency and internships.

Continue to engage nursing groups that have developed cohesive efforts to include safety issues in nursing programs.
Alliance for Nursing Informatics
American Association of Colleges of Nursing
National League for Nursing
American Organizations of Nurse Executives

Robert Wood Johnson Foundation has funded a nursing curriculum related to patient safety and informatics called Quality and Safety Education for Nursing Program.

IOM (Institute of Medicine). 2012.
Health IT and Patient Safety: Building Safer Systems for Better Care.
Washington, DC: The National Academies Press.
Concerns with Health IT
Customization and Standardization

• Standardization is necessary, but too much can unnecessarily restrict an organization.

• Institution-specific customizations presents challenges to maintenance, upgrades, sharing best practices, and interoperability across multiple-user organizations

• Health IT products are not finished products when it arrives on-site; this requires on-site completion and customization catered by the organization.

• Larger organizations have resources to customize their EHR, while smaller organizations with limited capabilities might revert to a paper workarounds.

• Vendors are encouraged to provide more complete and responsive health IT products in order to decrease the need for extensive customization.
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