First Do No Harm: Ensuring the Safe and Effective Use of Health IT (Text Version)

On September 14, 2009, Ross Koppel made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.0 MB). 

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First Do No Harm: Ensuring the Safe and Effective Use of Health IT AHRQ HIT Conference Sept, 2009

Ross Koppel, Ph.D.
Sociology Department, University of Pennsylvania & Center for Clinical Epidemiology & Biostatistics,
School of Medicine, University of Pennsylvania
rkoppel@sas.upenn.edu

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Matt's First Assignment

• Review relevant work

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JAMA, March 9, 2005

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

• Ross Koppel, PhD
• Joshua P. Metlay, MD, PhD
• Abigail Cohen, PhD
• Brian Abaluck, BS
• A. Russell Localio, JD, MPH, MS
• Stephen E. Kimmel, MD, MSCE
• Brian L. Strom, MD, MPH

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Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

• List of positives
• Noted 22 problems, e.g.:
  • Wrong: pt, med, dose, test-linked meds
  • Confused dose cancelling = doubling dose when want to reduce dose
  • Wrong dose guidance

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Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

• Ultimate Claim: CPOE good but not good enough
• Emperor not naked, but sometimes threadbare

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Methods

• Survey
• Shadowing
• Interviews with leaders
• Intensive interviews
• Many focus groups
• IT workers
• Much more

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Reaction

• Vendors
• New York Times
• Wall Street Journal
• Washington Post
• NPR
• Millions of web hits
• Within months, JBI devoted section of issue

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More Reaction

An image of David Brailer is shown.

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Next: About 25 Articles on HIT

An image of a stack of papers is shown.

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Harrison, Koppel & Bar-Lev (JAMIA, 2007) Interactive Sociotechnical Systems Analysis

An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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Also, Harrison, & Koppel, 2009) Interactive Sociotechnical Systems Analysis

An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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Harrison, Koppel & Bar-Lev (JAMIA, 2007) Interactive Sociotechnical Systems Analysis

An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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An image of the "Interactive Sociotechnical Systems Analysis" is shown

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Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety

• Ross Koppel, PhD,
• Tosha Wetterneck, MD, MS,
• Joel Leon Telles, PhD,
• Ben-Tzion Karsh, PhD

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Patient wrist barcode

An image of a doctor tending to a patient in a hospital bed is shown.

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On every medicine

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31 Causes of workarounds e.g.,

Unreadable medication-barcodes (crinkled, smudged, torn, missing, covered by another label)

Don't forget to scan label!

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Causes:

• Unreadable or missing patient-ID-wristbands (chewed, soaked, missing)
• Elderly, Children, Moving (unit or floor or nursing home)
• Failing batteries of handheld scanners or linked computers
• Difficult-to-read or navigate screens
• Alert beeps that sound like confirmation beeps
• Emergencies
• Pharmacies sending only partial doses
• About 20 others.

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Results 1: Fifteen identified workarounds (a) (Extra Copies)

• 1 example..Reproducing patients' wristband ID-barcodes, & affixing them to nursing station, computer cart, supply room, pt's room doorjamb, medication dispensing machine.

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Results 1: Fifteen identified workarounds (b)

• Continued.. RN clipboard, scanner itself, in nurses' pockets or on belt-rings, or worn as a group of bangles on nurse's sleeve.
• And 14 other workarounds

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JAMA March 25, 2009

An image of a news article from JAMA titled "Health Care Information Technology Vendors' "Hold Harmless" Clause" is shown.

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Two Clauses in HIT Vendor Contracts

• Who is responsible for errors? Even if hidden and embedded in the Software? And even if you are following the manual?

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Who can you tell? The Non-Disclosure Clause

An image of a safe is shown.

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Other Recent Publications of Note

• Comparison of 7 nation's use of CPOE. Health Affairs
• Ways of measuring medication errors using HIT. JAMIA
• Webinars and M&Ms Analysis of the 80 hour rule follow up on CPOE analysis of meaningful use.

Matt's 7 Questions

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1. Should the issue of EHR safety be built into the Initiatives supported in HITECH?

Wears & Leveson

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2. What should be the research agenda in this area?

• Focus on quality.
• But conventional methods limited.

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3. What roles should the government and private industry play? The JC?

1. I say..
2. Others say..
3. Industry and representatives want..

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The Government's Role

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4. How do we ensure that implementations of products are done in a way that ensures safety?

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5. In what ways are vendors and healthcare organizations interacting to ensure safe and effective use of EHRs?

If you build it well enough, they will want it

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6. Create a health IT usability lab. How funded? How to work it?

• Yes
• Funding: Gov't, Industry and Users
• Recognize it's limited to in vitro testing. Great idea, but only a start.

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No. 7 (condensed)

• The Health IT Extension Centers will help clinicians become meaningful users.
• How can we�incorporate�support to ensure safe and effective use of health IT into the�services that they provide?
• Who else should we help?

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Simple Answer:

Build better software:

• Training faster
• Less onerous
• Fewer battles with counter intuitive designs

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Thank you! Questions?

Ross Koppel, Ph.D.
Sociology Department, University of Pennsylvania &
Center for Clinical Epidemiology & Biostatistics,
School of Medicine, University of Pennsylvania
rkoppel@sas.upenn.edu