The Intersection of Health IT and Patient Safety—Lessons from the Field and Tools for Analysis

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Slide 1

The Intersection of Health IT and Patient Safety—Lessons from the Field and Tools for Analysis

Patient Safety and Health IT: ONC-sponsored SAFER Guides

Kathy Kenyon, Office of the National Coordinator (ONC) for Health IT
2012 AHRQ Annual Meeting, September 10, 2012.

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Health IT, Patient Safety

HHS is committed to leading on patient safety and aligning efforts with private sector.

• National Quality Strategy #1 Priority—Make care safer.
• Partnership for Patients—dramatically reduce hospital acquired conditions and unnecessary readmissions.
• Health IT is essential infrastructure.

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Institute of Medicine (IOM) Reports

• 1999—To Err is Human—epidemic of avoidable deaths requiring whole new approach to care delivery and patient safety.
• 2001 —Crossing the Quality Chasm—advocated widespread adoption of health IT as part of patient safety.
• 2011—Health IT and Patient Safety: Building Safer Systems for Better Care—
  • Health IT has enormous potential to improve patient safety.
  • Recommendations on how to—
    • Make health IT safer in complex sociotechnical environment of health care.
    • Learn from hazards and adverse events.
    • Implement effective oversight.
  • Patient Safety Action and Surveillance Plan.

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IOM: Is Health IT safe?

• Evidence isn't in yet.
  • Positive evidence is building.
• IOM Appendix—studies of large adverse event databases, health IT is involved in less than 1%.
• Health IT must be properly designed, maintained, and used.
  • But health IT is only one part of patient safety.
• Health IT can help make care safer.

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Health IT Patient Safety Policy

• Focus on patient safety first— build high reliability health care organizations with strong safety cultures.
• Use Health IT to make care safer:
  • How can it support Partnership for Patients?
• Make Health IT safer by integrating Health IT into existing patient safety and risk management programs; strengthen those programs using health IT:
  • How does Health IT fit into the culture of safety, Medicare conditions of participation, certification standards?
  • How can it support incident/adverse event reporting?
  • Provide Tools: SAFER Guides, Hazard Manager, and PSOs.

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ONC's Unintended Consequences Project

• Intentions for EHR incentive program are very, very good.
• BUT—ONC recognized possibility for unintentional negative consequences.
• Westat contract began in 2010.
• UC Technical Expert Panel with Work Groups on EHR Use, HIE, and Consumer eHealth.
• # 1 Unintended Consequence—safety issues.
• Hence: SAFER Guides (Safety Assurance Factors for EHR Resilience)
  • Initiation of SAFER Guides coincided with 2011 IOM Report.

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SAFER: Safety Assurance Factors for EHR Resilience

Provider self-assessment guides for critical error-prone processes in an EHR-based clinical work system.

• To be integrated into existing patient safety/risk management programs.
• Tailored for hospital and ambulatory settings.
• Expected completion September 2013.

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SAFER Guides

• The ordering process—computerized provider order entry (CPOE) and e-prescribing.
• System customization/configuration and upgrades.
• System to system interfaces such as that between CPOE and pharmacy systems.
• Patient identification processes.
• Clinical decision support.
• Provider communication during transitions of care.
• Laboratory results review processes.
• Downtime events.
• HIT safety-related human skills.

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Knowing how to make Health IT safer?

• SAFER Guides Project:
  • Experts, published research and case studies.
  • SAFER field research to test SAFER Guides.
  • Engaging "stakeholders"—associations, TJC, PSOs.
• ONC looks forward to more and better ways to know out how to make Health IT safer:
  • Hazard Manager.
  • PSOs and Common Formats re: impact of Health IT.
  • "Free flow of information" among EHR users.

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SAFER Guides and EHR Vendors

• ONC expects safe health IT from EHR vendors:
  • 2014 Edition of Certification: better user-centered design and quality management practices.
  • ONC supports facilitating use of Common Formats.
• Health IT safety is a "shared responsibility."
• SAFER Guides treat EHR users as primary audience, BUT assume that vendors are engaged and responsive to users.

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Questions

• ONC—kathy.kenyon@hhs.gov
• SAFER Guides—Westat:
  • Dean F. Sittig, PhD, School of Biomedical Informatics, University of Texas- Memorial Hermann Center for Healthcare Quality & Safety, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX. (dean.f.sittig@uth.tmc.edu)
  • Joan S. Ash, PhD, MLS, MBA, Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, OR. (ash@ohsu.edu)
  • Hardeep Singh, MD, MPH, Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX. (hardeeps@bcm.edu)