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

Slide presentation from the AHRQ 2009 conference.

 

On September 14, 2009, Carla Smith made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (258 KB).

Slide 1

First Do No Harm: Ensuring the Safe and Effective Use of Health IT

AHRQ 2009 Annual Conference
Bethesda, MD - Monday September 14, 2009, 3-4:30pET

Carla Smith, CNM, FHIMSS
Executive Vice President

 

 

Slide 2

Overview

  • HIMSS Background
  • Review Questions
  • Highlight Relevant HIMSS Activities
    • Davies Award
    • Usability White Paper
  • Questions

 

Slide 3

HIMSS Strategic Direction

Vision
Advancing the best use of information and mgt systems for the betterment of health care.

Mission
Lead healthcare transformation through the effective use of health information technology.
 

 

Slide 4

Role of Health IT in preventing errors

  • Role of Health IT in preventing errors
  • Role of Health IT in introducing errors
  • How to ensure the safe and effective use of Health IT

 

Slide 5

Role of Health IT in preventing errors

  • Provide availability of information to providers
  • Improve collaboration between providers
  • Reduce human error at the point of care through Clinical Decision Support (alerts and rules) based on standard clinical norms and guidelines
  • Provide workflow automation and improvement
  • Enable Computerized Provider Order Entry (CPOE) and reduction of adverse drug events
  • Enable the 5 Rights of Medication Administration

 

Slide 6

Clinical Decision Support (CDS)

  • Detect potential safety and quality problems and help prevent them
  • Detect inappropriate utilization of services, medications, and supplies
  • Foster the greater use of evidence-based medicine principles and guidelines
  • Organize, optimize and help operationalize the details of a plan of care
  • Help gather and present data needed to execute this plan
  • Ensure that the best clinical knowledge and recommendations are utilized to improve health management decisions by clinicians and patients

Osheroff JA, Pifer EA, Teich JM, et al. Improving Outcomes with Clinical Decision Support: An Implementers' Guide. Chicago: HIMSS; 2005.

 

Slide 7

Role of Health IT in introducing errors

  • Role of Health IT in preventing errors
  • Role of Health IT in introducing errors
  • How to ensure the safe and effective use of Health IT

 

Slide 8

Unintended or Unwanted Consequences

  • Iatrogenesis:
    • Not new in the literature
      • Unintended harm caused by clinicians
  • E-Iatrogenesis - electronic iatrogenesis
    • Unintended consequences through the use of computerized provider order entry (CPOE)

 

Slide 9

Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry JAMIA, April 2007: 12:315-423

  • System demands
    • Need for continuous equipment upgrades
  • Extended workflow
    • Extra time to enter orders
  • Power shifts
    • Decisions made by ancillary clinical staff
    • Improved collaboration and sharing among sites*
  • New error types
    • Entering orders on the wrong patient
    • Incongruence of process change with existing mental model*
    • Hand-offs*
  • Dependence on the system
    • Downtime
    • Defaults leading to increased errors*
  • More work or new work
    • Non-standard cases, call for more steps in ordering
    • Additional post-live education and support requirements*

* Examples from Allina Hospitals & Clinics, 2007 Davies Organizational Award

 

Slide 10

How to ensure the safe and effective use of health IT

  • Role of health IT in preventing errors
  • Role of health IT in introducing errors
  • How to ensure the safe and effective use of health IT

 

Slide 11

How to ensure the safe and effective use of Health IT

  • Involve care providers
  • Engage facility leadership
  • Utilize the 13 Joint Commission Suggested Actions
  • Follow EMR Usability Principles
  • Relentless Discovery of New Patient Safety Solutions to Emerging Problems

 

Slide 12

Joint Commission Sentinel Event Alert No. 42

  • Examine workflow processes and procedures
  • Actively involve clinicians and staff
  • Assess your organization's technology needs beforehand
  • During the introduction of new technology, continuously monitor for problems
  • Establish a training program
  • Develop and communicate policies delineating staff authorized and responsible
  • Prior to taking a technology live, ensure that all standardized order sets and guidelines are developed, tested on paper, and approved by the Pharmacy and Therapeutics Committee (or institutional equivalent).

 

Slide 13

Joint Commission Sentinel Event Alert No. 42

  • Develop a graduated system of safety alerts in the new technology that helps clinicians determine urgency and relevancy.
  • Develop a system that mitigates potential harmful CPOE drug orders by requiring departmental or pharmacy review and sign off on orders that are created outside the usual parameters.
  • To improve safety, provide an environment that protects staff involved in data entry from undue distractions when using the technology.
  • After implementation, continually reassess and enhance safety effectiveness and error-detection capability.
  • After implementation, continually monitor and report errors and near misses or close calls caused by technology through manual or automated surveillance technique.
  • Re-evaluate the applicability of security and confidentiality protocols as more medical devices interface with the IT network.

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

 

Slide 14

Davies Award

 

Slide 15

Davies Awards of Excellence

  • Encourages and recognizes excellence in the implementation of HER
  • Systems
    • Implementation
    • Strategy
    • Planning
    • Project Management
    • Governance
    • Value and ROI
  • Objectives
    • Promote the vision of EHR Systems through concrete examples
    • Understand and share documented value of EHR Systems
    • Provide visibility and recognition for high-impact EHR Systems
    • Share successful EHR imlementation strategies

 

Slide 16

During the introduction of new technology, continuously monitor for problems

Office of the CMIO- Ongoing Feedback

  • CPOE intranet
    • Clinical staff send questions and/or feedback
    • Feedback reviewed by:
  • Team of clinical coordinators (from the Office of the CMIO), Information Systems staff and clinical educators
  • Identify, resolve technical, process or training issues
  • Intranet provides complete transparency
    • Site displays all the issues the user reported since CPOE was implemented
  • "CMIO Newsletter"
    • Articles on CPOE, other EHR implementation status, Service and Section meetings

Eastern Maine Medical Center - '08 Davies Organizational Award

 

Slide 17

Alert Fatigue

Graduated system of safety alerts in the new technology that helps clinicians determine urgency and relevancy

  • Overriding alerts without reading the alerts
    • Documented unintended consequence of CPOE
  • To minimize this risk, EMMC opted to
    • Start slowly with the minimum number of alerts firing to the providers
    • ...But all firing to the pharmacists
  • Reduction in drug-drug alert firing to providers
    • Significantly decreased the "noise" and negative impact on provider ordering while maintaining patient safety
  • 17,498 alerts/month to 2,401 alerts/month

Eastern Maine Medical Center, Davies '08 Organizational Award of Excellence

 

Slide 18

EMR USABILITY

 

Slide 19

EMR Usability

  • "Defining and Testing EMR Usability"
    • Effectiveness
    • Efficiency
    • Satisfaction

http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf

 

Slide 20

EMR Usability Principles

  • Simplicity
  • Naturalness
  • Consistency
  • Minimizing cognitive load
  • Efficient interactions
  • Forgiveness
  • Feedback
  • Effective use of language
  • Effective information presentation
  • Preservation of context

 

Slide 21

Example Simplicity

An image of the "Details needed in managing new medications and refills" and "Details needed in the overall dashboard view" is shown.

 

Slide 22

For additional information:

Carla Smith, CNM, FHIMSS
Executive Vice President
HIMSS
(734) 477-0860 office
(734) 604-6275 cell
csmith@himss.org

 

Slide 23

BACKGROUND

 

Slide 24

CDS: (How) Does it Work?

Two Examples

  • Medications
    • Suggesting brand to generic substitutions for medications, alternative, more cost-effective therapies, or more formulary compliant drug options
    • Selecting complex dosages (renal failure or geriatrics) and supporting drug-level monitoring are additional advantages of CDS
  • Radiological tests and procedures
    • Support at the point of ordering can guide physicians toward the most appropriate and cost effective, radiological tests

Osheroff JA, editor. Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step Guide. Chicago: HIMSS; 2009. (www.himss.org/cdsguide)

 

Slide 25

Davies: Role of Health IT in Preventing Errors

CDS

  • Alerts and reminders
  • Clinical guidelines
  • Order sets
  • Patient data reports, dashboards
  • Documentation templates
  • Diagnostic support
  • Reference information
  • Decision support feature identified 164,250 alerts, resulting in 82,125 prescription changes
  • Problem medication orders dropped 58%, medication discrepancies by 55%
  • Addressed "high alert medications," confusing look-a-like and sound-alike drug names, patients with similar names

Maimonides Medical Center, 2002 HIMSS Davies Organizational Award

 

Slide 26

Davies: Role of Health IT in Preventing Errors

Allina Hospitals & Clinics, 2007 HIMSS Davies Organizational Award

  • CDS
  • Alerts and reminders
  • Clinical guidelines
  • Order sets
  • Patient data reports, dashboards
  • Documentation templates
  • Diagnostic support
  • Reference information
  • Created a process to reduce drug utilization
  • Ability to generate a system list of specific IV medications, which can be changed to PO medications without contacting a provider
    • PO medications are a less costly route of therapy
    • Chance of infection from IV use is decreased
    • Average length of stay is reduced
    • Pharmacy and Nursing time to prepare and administer medication is reduced

 

Slide 27

Davies: Role of Health IT in Preventing Errors

  • CDS
  • Alerts and reminders
  • Clinical guidelines
  • Order sets
  • Patient data reports, dashboards
  • Documentation templates
  • Diagnostic support
  • Reference information
  • New procedures regarding a medication could be introduced in just hours
    • Problems with Dilaudid, e.g, brought about different recommended doses in patients
  • Changed 32 order sets and 22 preference lists in 3 hours
  • Omitted administration of medications decreased 22% from a total of 18 to 14 a month

Evanston Northwestern Healthcare, 2004 HIMSS Davies Organizational Award

 

Slide 28

Davies: Role of Health IT in Preventing Errors

  • CDS
  • Alerts and reminders
  • Clinical guidelines
  • Order sets
  • Patient data reports, dashboards
  • Documentation templates
  • Diagnostic support
  • Reference information
"Pre-EHR"...
  • Offices relied on the patients to return for repeat INR blood tests
    • 7,267 patients in the practice currently prescribed warfarin (an unknowable # prior to EMR)
"EHR"...
  • Customized encounter form for warfarin management
    • Weekly reports
      • Identifies patients overdue
        • Patients overdue as much as 6 to 12 months
        • Nurses contact patients, facilitate compliance with anticoagulation monitoring.

Cardiology Consultants of Philadelphia, 2008 HIMSS Davies Ambulatory Award

 

Slide 29

Davies: Role of Health IT in Preventing Errors

  • CDS
  • Alerts and reminders
  • Clinical guidelines
  • Order sets
  • Patient data reports, dashboards
  • Documentation templates
  • Diagnostic support
  • Reference information
Device Recall:
  • Medtronic's Fidelis defibrillator lead
    • Queried EHR database
      • Able to identify all patients implanted with this lead, 10 minutes after recall notification
      • Identified 100+patients beyond those identified in the records of the device manufacturer
    • Mail-merge form letters created
      • Notified all patients within hours (not weeks as pre-EHR)
      • Device manufacture modified their local processes for collecting implanted lead data

Cardiology Consultant of Philadelphia, 2008 HIMSS Davies Ambulatory Award
 

 

Slide 30

Davies: Role of Health IT in Preventing Errors

  • CDS
  • Alerts and reminders
  • Clinical guidelines
  • Order sets
  • Patient data reports, dashboards
  • Documentation templates
  • Diagnostic support
  • Reference information
  • Improved allergy documentation 88%-100%
  • Improved pain assessment documentation-95%
  • Improved medication list documentation 67%-100%

Maimonides Medical Center, 2002 HIMSS Davies Organizational Award
 

 

Slide 31

Role of Health IT in Preventing Errors

  • CDS
  • Alerts and reminders
  • Clinical guidelines
  • Order sets
  • Patient data reports, dashboards
  • Documentation templates
  • Diagnostic support
  • Reference information
  • Regional PACS (Picture Archiving and Communication System):
    • Enables access to images and concurrent review by multiple providers in separate locations across the region, thereby, improving the clinical effectiveness and patient outcomes
    • Radiologists and other specialists can access studies for timely online comparison from the same PACS system allowing broad and rapid access to images

Eastern Maine Medical Center, 2008 HIMSS Davies Organizational Award

 

Slide 32

Role of Health IT in Preventing Errors

  • CDS
  • Alerts and reminders
  • Clinical guidelines
  • Order sets
  • Patient data reports, dashboards
  • Documentation templates
  • Diagnostic support
  • Reference information
Access to drug references:
  • Desktop access via the intranet is possible to Micromedex, OVID, ENH* Formulary, ENH Drug Use Guidelines, ENH Policy & Procedures, IV Administration Guidelines, and several other secondary and tertiary medical references.

Evanston Northwestern Healthcare (*ENH), 2004 HIMSS Davies Ambulatory Award

 

Slide 33

Role of health IT in introducing errors

  • Role of health IT in preventing errors
  • Role of health IT in introducing errors
  • How to ensure the safe and effective use of health IT

 

Slide 34

Unintended or Unwanted Consequences

  • Iatrogenesis:
    • Not new in the literature
      • Unintended harm caused by clinicians
  • EIatrogenesis - electronic iatrogenesis
    • Unintended consequences through the use of computerized provider order entry (CPOE)

 

Slide 35

Joint Commission Sentinel Event Alert No. 42 Dec '08

176,409 medication error records for '06, 1.25% resulted in harm

Cause Number %
Barcode, medication mislabeled 20 5
Information management system 1,176 2
Computer screen display unclear/confusing 137 1.5
Dispensing device involved 3,181 1.3
Barcode, failure to scan 141 <1
Computer entry (general, other than CPOE) 24,715 <1
CPOE 10,752 <1
Barcode, override warning 41 0

 

Slide 36

The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry, JAMIA, April 2007: 12:315-423

  • More or new work
  • Extended workflow
  • System demands
  • Emotions
  • New kinds of errors
  • Power shifts
  • Dependence on the system
  • Non-standard cases call for more steps in ordering
  • Extra time to enter orders
  • Need for continuous equipment upgrades
  • Both positive & negative
  • Entering orders on the wrong patient
  • Decisions made by ancillary clinical staff
  • Downtime creates a major issue

 

Slide 37

Lessons Learned: Unanticipated Consequences

Allina Hospitals & Clinics,'07 HIMSS Davies Organizational Award

  • Hand Offs - New Issues
  • Novice Errors - Medications
  • Nurse/Physician Communication
  • Defaults leading to increased errors
  • Improved collaboration and sharing among sites
  • Individual growth
  • Rapid Dependence on Automation
  • Additional post-live education and support requirements
  • Incongruence of process change with existing mental model
  • Emotions
  • Order Sets

 

Slide 38

Human Factors - Lessons Learned: Unanticipated Consequences

  • Scanning troubles-low contrast. Some older prefilled fluid and medication bags had bar codes that identified their contents (great!) but these codes were printed in white ink on clear bags, rendering scanning impossible.
  • Mitigating Strategy Most fluid and medication suppliers have moved to higher-contrast printing, typically black or blue on clear bags.
  • Other Examples Integrating Medical Devices with Clinical Documentation Systems: A Quick-Start Guide

www.himss.org/ASP/topics_FocusDynamic.asp?faid=295
 

 

Slide 39

Joint Commission Sentinel Event Alert No. 42

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

  • Safety and effectiveness of technology in health care ultimately depend on its human users, ideally working in close concert with properly designed and installed electronic systems.
  • Any form of technology may adversely affect the quality and safety of care if it is designed or implemented improperly or is misinterpreted.
  • Not only must the technology or device be designed to be safe, it must also be operated safely within a safe workflow processes.

 

Slide 40

Joint Commission Sentinel Event Alert No. 42

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

  • Examine workflow processes and procedures
  • Actively involve clinicians and staff
  • Assess your organization's technology needs beforehand
  • During the introduction of new technology, continuously monitor for problems
  • Establish a training program
  • Develop and communicate policies delineating staff authorized and responsible
  • Prior to taking a technology live, ensure that all standardized order sets and guidelines are developed, tested on paper, and approved by the Pharmacy and Therapeutics Committee (or institutional equivalent).

 

Slide 41

Office of the CMIO- Ongoing Feedback

During the introduction of new technology, continuously monitor for problems
 

  • CPOE intranet
    • Clinical staff send questions and/or feedback
    • Feedback reviewed by:
      • Team of clinical coordinators (from the Office of the CMIO), Information Systems staff and clinical educators
      • Identify, resolve technical, process or training issues
    • Intranet provides complete transparency
      • Site displays all the issues the user reported since CPOE was implemented
  • "CMIO Newsletter"
    • Articles on CPOE, other EHR implementation status, Service and Section meetings
    • Eastern Maine Medical Center - '08 Davies Organizational Award

 

Slide 42

Joint Commission Sentinel Event Alert No. 42

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

  • Develop a graduated system of safety alerts in the new technology that helps clinicians determine urgency and relevancy.
  • Develop a system that mitigates potential harmful CPOE drug orders by requiring departmental or pharmacy review and sign off on orders that are created outside the usual parameters.
  • To improve safety, provide an environment that protects staff involved in data entry from undue distractions when using the technology.
  • After implementation, continually reassess and enhance safety effectiveness and error-detection capability.
  • After implementation, continually monitor and report errors and near misses or close calls caused by technology through manual or automated surveillance technique.
  • Re-evaluate the applicability of security and confidentiality protocols as more medical devices interface with the IT network.

 

Slide 43

Alert Fatigue

Graduated system of safety alerts in the new technology that helps clinicians determine urgency and relevancy

  • Overriding alerts without reading the alerts
    • Documented unintended consequence of CPOE
  • To minimize this risk, EMMC opted to
    • Start slowly with the minimum number of alerts firing to the providers
    • .But all firing to the pharmacists
  • Reduction in drug-drug alert firing to providers
    • Significantly decreased the "noise" and negative impact on provider ordering while maintaining patient safety
  • 17,498 alerts/month to 2,401 alerts/month

Eastern Maine Medical Center, Davies '08 Organizational Award of Excellence

 

Slide 44


  • Collect and Report Care and Revenue Cycle Information in a Standardized Meaningful Way
    • Core and Community Measures
    • Reports provided for individual practitioner achievement vs. the goal
    • Sites celebrate their achievement of optimal care goals

Allina Hospitals & Clinics, 2007 HIMSS Davies Organizational Award

 

Slide 45

  • Hard Wire Best Practices Across the System Quickly
    • Order Sets
    • Best Practice Alerts
    • Rules
    • Plans of Care

Allina Hospitals & Clinics, 2007 HIMSS Davies Organizational Award

 

Slide 46

  • Impact Care Proactively and at the Time of Patient Contact
    • Order Sets
    • Rules and Alerts
    • Medication Recalls
    • Real Time Reporting
    • Atherosclerosis Pilot
    • Diabetes Patients Entering Data into Chart

Allina Hospitals & Clinics, 2007 HIMSS Davies Organizational Award

Current as of December 2009
Internet Citation: First Do No Harm: Ensuring the Safe and Effective Use of Health IT (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/news/events/conference/2009/smith2/index.html

 

The information on this page is archived and provided for reference purposes only.

 
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