Electronic Health Records: Recognizing and Managing the Risks

Size: px
Start display at page:

Download "Electronic Health Records: Recognizing and Managing the Risks"


1 Caims cinica & risk management perspectives October 2009 Eectronic Heath Records: Recognizing and Managing the Risks CME Information Sponsored by: NORCAL Mutua Insurance Company. NORCAL Mutua Insurance Company is accredited by the Accreditation Counci for Continuing Medica Education to provide continuing medica education for physicians. Method and Medium To obtain CME credit, read the enduring materia artice, and compete and return the attached activity Evauation and CME Attestation Form no ater than the expiration date indicated beow. Origina Reease Date: October 2009 Expiration Date: October 31, 2010 Learning Objectives By reviewing the cases presented in this course and impementing the risk management recommendations, you wi increase your abiity to: Adopt and adhere to eectronic communication and documentation standards. Utiize the EHR system productivey whie continuing to impement patient safety practices, such as doube-checking medication dosages, using an effective foow-up system and reviewing records for accuracy. Deveop poicies and procedures specificay reated to training in the safe use of the EHR system. Target Audience A providers Credit Designation Statement NORCAL Mutua Insurance Company designates this educationa activity for a maximum of 1 AMA PRA Category 1 Credit Ṭ M Physicians shoud ony caim credit commensurate with the extent of their participation in the activity. Discosure Poicy As an ACCME accredited provider, NORCAL Mutua Insurance Company requires panners, reviewers or authors who infuence or contro the content of a CME activity to discose financia reationships (of any amount) they have had with commercia interests associated with this CME activity during the year preceding pubication of the content. Any identified conficts of interest are resoved prior to the commencement of the activity. Discosures Individuas invoved in the panning, reviewing or execution of this activity have indicated they have no reevant financia reationships to discose. Editor Mary-Lynn Ryan Consuting Risk Management Speciaist, NORCAL Content Advisors David R. Hoey, MD Chairman, NORCAL Board of Directors Harry B. Richardson, Jr., MD Vice Chairman, NORCAL Board of Directors Wiiam R. Vetter, MD Secretary, NORCAL Board of Directors Patricia A. Daiey, MD NORCAL Board of Directors Michae Stephens NORCAL Board of Directors Newe E. Warde, PhD NORCAL Board Advisory Counci Executive Director,Rhode Isand Medica Society James Sunseri President & CEO, NORCAL Stephen M. Farber Vice President, Risk Management, NORCAL Nei Simons Vice President, Underwriting-Marketing- Poicyhoder Services, NORCAL Jane Tishkoff, Esq. Associate Vice President and Assistant Genera Counse, NORCAL Marene Nazarey, RN, MSN Manager, Risk Management, NORCAL Dustin Shaver Manager, Risk Management, NORCAL Paua Snyder, RN, CPHRM Manager, Risk Management, PMSLIC John Resetar Supervisor, Caims Department, NORCAL Panners Jo Townson Risk Management Speciaist, NORCAL Sonia Rutherford Risk Management CME Program Services Coordinator, NORCAL

2 Introduction Eectronic heath records (EHRs) hod great promise of improving patient safety and decreasing medica iabiity exposure, but their use is creating a variety of new risk management and patient safety issues. Some of these issues are directy associated with EHRs (e.g., providers disregard warnings generated by the EHR), but many of the risk concerns associated with EHRs are anaogous to probems that currenty exist in paper documentation systems. In this month s Caims Rx we present a number of shorter-than-usua case studies that exempify various aspects of unsafe EHR documentation and communication practices. The scenarios are based on NORCAL cosed caims, facts presented in appeate opinions, research findings and the observations of NORCAL Risk Management Speciaists. What many of the exampes show is that EHRs do not eiminate many of the dangerous documentation and communication practices that have historicay ed to patient injury and mapractice awsuits. Consequenty, whie it is important to address new issues that arise with EHRs, many of the risk management recommendations that appy to a paper-based documentation system remain vaid. This Caims Rx wi discuss the risks associated with various aspects of EHRs and wi provide guidance for instituting poicies and procedures designed to enhance the quaity and safety of patient care, whie diminishing professiona iabiity risk. Federa EHR Incentive Program In February of this year, President Barack Obama signed the American Recovery and Reinvestment Act (ARRA), which sets aside $17.2 biion doars of the economic stimuus package for incentive payments to Medicare and Medicaid providers who impement EHRs according to standards that are projected to be avaiabe by the end of 2009.* The payouts begin in Eary adapters who can demonstrate meaningfu use of EHRs (among other features, the system must have e-prescribing, can connect with other EHRs and can report cinica quaity measures) are eigibe for the highest reimbursement amounts. The reimbursement amount diminishes by year, up through For Medicare providers, the payout maximum is $44,000 over five years. For Medicaid it is neary $64,000 over six years. In 2015, providers who cannot demonstrate meaningfu use may have their Medicare rates diminished by 1%. This increases to 2% in 2016 and 3% in 2017 and may rise even higher in future years. Medicaid does not have a simiar penaty structure. As coud be expected, EHR vendors are aggressivey marketing their products. It can take over a year to get an EHR system up and running, so being eigibe for the 2011 stimuus payment coud be a rea chaenge for someone who waits too ong to make the initia EHR investment. It is important, however, to consider severa aspects of the incentive payment egisation before investing in an EHR for the purpose of coecting a 2011 reimbursement. For exampe, the rues coming out at the end of the year are supposed to further define meaningfu use and are expected to detai the nature of physician-to-physician data exchange requirements, describe cinica quaity measures that must be reported to the U.S. Department of Heath and Human Services (HHS) and describe the process of certification.* Despite the possibe oss of the first incentive payment, providers are urged to carefuy consider which EHR is appropriate for their practice and aow an appropriate amount of time for training and roing out the new system. CaimsRx page 2

3 Federa EHR Incentive Program (continued) EHR Impementation Resources A variety of organizations provide further information on the various aspects of converting from paper to eectronic records, incuding: Joint Commission The Joint Commission pubished Safey impementing heath information and converging technoogies, Sentine Event Aert 42, December 11, 2008, which makes patient safety recommendations reated to EHR impementation. It is avaiabe on the Joint Commission Web site at: (accessed 8/24/2009). American Academy of Famiy Physicians (AAFP) Through its Center for Heath Information Technoogy Web site, the AAFP offers advice on every step of an EHR conversion: (accessed 8/24/2009). References * Mariyn Lamar, Esq. Embracing benefits, facing risks with EHR technoogy. Presented by ASHRM on 8/4/2009. Stephen H Carson, MD. Eectronic Heath Record: Beware. San Joaquin Physicians. Summer Robert Lowes. Experts Offer EHR Advice in Light of New Federa Incentives. May 14, Avaiabe on the Medscape Web site at: (accessed 8/24/2009). Data Entry Errors EHRs may decrease errors caused by uninteigibe handwriting, but they cannot be expected to eradicate human error. Providers are encouraged to question EHR information that does not seem right (e.g., abnormay high medication dosages, radiographic images that are not consistent with the patient s anatomy, etc.) and attempt to reconcie conficting information. Saving Images in the Wrong Patient s Chart Just as an image can be misfied or ost in a paper system, it can be misfied in an eectronic one. However, as the foowing case shows, it can be ess obvious that an image has been misfied in an eectronic system. Case Study Patient #1 and patient #2 both presented to the Emergency Department (ED) compaining of abdomina pain. CT scans of the abdomen and pevis were competed for both patients. A radioogy tech mistakeny gave patient #2 s images the identification number assigned to patient #1 and upoaded the images into the Picture Archiving Computer System (PACS). A short time ater, the tech reaized his mistake and caed the on-duty teeradioogist to te him about the mistake and request that the misabeed images be deeted from the system. However, the on-duty teeradioogist did not have access to deete images from the PACS; this had to be done by the PACS administrator. The tech then corrected the abeing probem and sent the images out to the teeradioogy service for a preiminary review and resent the correcty abeed images to the PACS. Patient #1 s PACS fie now contained both his own and patient #2 s images. A few days ater the tech tod his supervisor about the misabeing, and assumed that the supervisor woud remedy the probem. Pursuant to hospita poicy, the tech shoud have immediatey contacted the PACS administrator. The teeradioogy service reported that patient #1 s CT scan was norma. Patient #2 s CT scan, however, showed a arge tumor (about the size of a grapefruit) on the patient s kidney. The service faxed the reports to the radioogy department at the hospita. (continued on page 4) CaimsRx page 3

4 ( Data Entry Errors... continued from page 3) The next morning, the on-duty radioogist reviewed the PACS images from the night before. He disregarded the teeradioogy service reports because they did not correspond to what he saw in the PACS. Because patient #2 s scan had been competed before patient #1 s, patient #2 s images were the first series in his fie. The on-duty radioogist noted the arge tumor and dictated a note. Because patient #2 s images sti carried patient #1 s identification number, the radioogist s report was assigned to patient #1. Patient #1 was subsequenty seen by a number of speciaists for the supposed tumor on his kidney. Seven days after the CT scan, he underwent a nephrectomy. During the surgery, no mass coud be positivey identified on his kidney by his surgeons. Postoperativey, no tumor was identified in the removed kidney and pathoogy returned benign. (Pease note, once the fiing mistake was recognized, patient #2 was notified and underwent a timey and successfu nephrectomy.) Discussion A combination of system probems and communication issues ed to this patient s unnecessary surgery. It probaby never woud have occurred if the tech had either foowed the poicy of aerting the PACS administrator of his error or had had the capacity to deete an image that he had misabeed. He shoud have known that neither the teeradioogist nor his immediate supervisor woud be abe to deete images from the PACS. The probem was compounded by the radioogy department s ateration of the EHR system. In its atered state, two series of images automaticay opened up on two viewing screens one screen showing the scout fims and the other screen showing the cuts. The radioogists needed to cick on a sma button on one of the monitors marked series to see any other fims. In this case, the radioogist did not suspect any other fims were taken, so he had no reason to cick on the series button. Another probematic issue was the radioogist s faiure to ook further into why the PACS images he saw were entirey inconsistent with the fax report he received from the radioogy service. He was in the habit of disregarding the service s reports because he thought they were consistenty inaccurate. Lasty, the surgery team went through with the nephrectomy despite the surgeon recognizing that the patient s anatomy did not correspond to the CT image on the wa that showed a very arge tumor. Risk Management Recommendations If something in the EHR does not make sense, doube check it. Do not assume that the information is correct simpy because it is in the EHR. If you make a mistake in a person s record and have to depend on someone ese to correct it, go back to the patient s record to confirm that the record has been appropriatey corrected. Continuay assess whether EHR reconfigurations increase patient safety and reduce professiona iabiity risk exposure; if they don t, find aternative means to achieve needed aterations to the system. Ensure that staff and cinicians are aware of EHR poicy and that they are foowing it. Checking the Wrong Box In the foowing case, the appearance of the computer screen probaby payed a roe in the medication error. Case Study A patient presented to his primary care physician (PCP) for the treatment of headaches and episodes of atered consciousness. The PCP prescribed amitripyine at 10 mg nighty. The PCP tod the patient to escaate the dosage by 10 mg every three to four days unti the pain was reieved, but not to exceed 50 mgs without consuting him. When creating the prescription, the PCP intended to check off the 10-mg box in the computerized physician order entry (CPOE), but inadvertenty checked the 100-mg box, which was right above it. In the medication instructions section, he indicated that five pis coud be taken per night, so the patient woud not have to return to the pharmacy and pay an additiona co-pay if he utimatey needed the arger dose. Caims Rx page 4

5 The pharmacist had noticed that the dose seemed high and requested that a ca be made to the PCP prior to it being dispensed. A nurse at the PCP s office picked up the ca, and because she was very busy that day, tod the pharmacy to dispense the medication as it had been ordered she did not check the dose. Three days ater, the patient took five of the 100-mg pis together. Eary the next morning, the PCP was contacted by an emergency department (ED) physician who reported that the patient was in the ED reporting dizziness, an atered state of consciousness, an inabiity to coordinate his movements and a rapid heartbeat. He was further informed by the ED physician that the patient had taken five 100-mg amitripyine tabets. The PCP then checked the patient s record and reaized his mistake. Discussion In this case, the nurse assumed that because the dosage had come from the system, it was correct. As this case indicates, however, a typographica error can be as dangerous as iegibe handwriting. It is important to recognize probems with an EHR and attempt to get them soved so they are ess ikey to resut in treatment errors. For exampe, in this case, the provider coud contact his EHR vendor and attempt to work out a way to move the check boxes associated with dosage amounts further apart on the drug ordering screen or have a pop-up box that confirms the ordered medications before cosing out of the record. Genera Medication Transcription Risk Management Recommendations In addition to appropriatey foowing up on dosage questions (which the nurse in this case obviousy did not do), an EHR system shoud be configured to appy the risk management tactics that appy to paper records, and when such functions are not avaiabe, paperrecord tactics shoud be used in making entries in the eectronic record: Incude a brief notation of the purpose on a prescription orders (e.g., for cough), uness considered inappropriate by the prescribing physician. Record a prescription orders in the metric system except for therapies that use standard units such as insuin, vitamins, etc. Incude age and, when appropriate, weight of the patient on the prescription or medication order. Incude drug name, exact metric weight or concentration and dosage. Aways precede a decima expression of ess than one with a eading zero. Do not use a termina or taiing zero after a decima. Avoid using abbreviations incuding those for drug names (e.g., spe out unit and internationa unit rather than writing U or I.U. ; use daiy or every other day, whichever is appicabe, not q.d. or q.o.d. ). m The Institute for Safe Medication Practices (ISMP) pubishes a ist of unacceptabe abbreviations and symbos, which is avaiabe on the ISMP Web site at: (accessed 8/24/2008). Typing the Wrong Dose Athough some EHR systems fag medication doses that are abnormay high, as the previous and the upcoming case studies show, there are dosage errors that wi sip through the cracks. Case Study A 75-year-od man presented to a cardioogist s office to estabish care. He had a history of moderate pumonary hypertension, hyperipidemia, chronic gout, gaucoma, choecystectomy, and presbycusis. The patient had been taking various medications, incuding a 0.25-mg Xanax tabet prior to schedued appointments to reieve his anxiety. The medica assistant (MA) responsibe for rooming the patient took the patient s copy of his medication ist and noted that the patient was taking Xanax (aprazoam) 2-mg tabs prn in the eectronic medica record. The prescription for Xanax 2 mg tabs prn was refied at the patient s pharmacy. Three months ater, the patient presented to his ophthamoogist. Prior to the appointment, he took a 2-mg Xanax tabet to aeviate his anxiety. On his way home he fe aseep behind the whee and crashed into a tree. After the accident, the physician reviewed the (continued on page 6) Caims Rx page 5

6 ( Data Entry Errors... continued from page 5) patient s medica record and recognized that the MA had entered Xanax 2 mg tabs prn. Unfortunatey, the physician had gotten into the habit of signing off on the medica assistant s entries without reay reviewing them. Discussion The foregoing case exampe shows that caution must be used when recording patient information, even when it is captured and entered into an EHR. The physician in this case reied on an MA to accuratey transcribe the patient s medication ist into the EHR, and there was no verification process in pace. Once the origina entry made it into the patient s record, it was never reviewed. Transcription errors are often caused by cerica staff members who misunderstand an order or have difficuty reading an origina document because of iegibiity. 1 According to one study, mutifaceted intervention invoving providers and patients can significanty improve medication ist discrepancies in an eectronic medica record. Essentia interventions in the study incuded maiing etters to patients before appointments to remind them to bring a medication bottes or an updated medication ist to their cinic visit and having the patient verify the most recent medication ist in the eectronic medica record. Athough these methods significanty reduced discrepancies, they did not competey eiminate them. The study authors recommended further system designs such as medication cards and/or nurse- or software-aided coection of medication ists from patients before visits. 2 Risk Management Recommendations Ensure that a icensed heathcare professiona doube-checks medications transcribed into an eectronic medica record. Institute procedures that reguary update and reconcie patient medication ists. Mai etters prior to appointments asking patients to bring in a prescription medications and overthe-counter medications to appointments. m Generate an eectronic medication ist and compare the eectronic ist to the medication bottes whie the patient is in the office. If patients do not bring in medication bottes, enist the patient to ensure the accuracy of the eectronic medica record medication ist. m Ask the patient to compare the medication ist generated from an eectronic record with medication bottes at home. System-Assisted Documentation The issue of incompete/inaccurate documentation takes a variety of forms in the EHR arena. Functions in an eectronic record that were designed to save time have created a whoe new set of risk management issues. Case Study A 50-year-od woman presented to the ED compaining of neck and eg pain. The ED physician did his exam from the doorway of the patient s room using his tabet PC. He checked off items on the eectronic T-sheet whie he asked a few basic questions. It took him ess than one minute. Out of curiosity, an ED nurse who was present reviewed his documentation. She found that there was a comprehensive assessment documented. 3 Discussion The foregoing case study provides an exampe of documentation that uses a tempate to sef-generate certain aspects of the patient s record. This EHR function (aso referred to as an expoding note ) aows users to pu up a tempate for a particuar condition and then check boxes indicating norma or abnorma vaues or observations. An examination note in paragraph form is then produced for the EHR. In the foregoing case, the ED physician was engaging in a practice that may be considered frauduent biing by the Centers for Medicare and Medicaid Services (CMS). From a medica iabiity standpoint, if this physician s treatment came into question, it woud be difficut for him to convincingy support the adequacy of his assessment. If sef-popuating forms are used, it is important to go through the entire form and ensure that the note that has been created accuratey refects the patient s condition. Caims Rx page 6

7 A practice referred to as coning can resut in simiar documentation inaccuracies. Coning refers to copying information from an earier exam and pasting the information into the record for a current exam. This can occur in the same patient s chart or between different patients. Athough it is considered appropriate to copy a compex medica history from an earier exam, providers shoud not use coned content for a patient s history of a present iness, the exam or the medica decision-making process and particuary not for a different patient. 4 Using the EHR to document treatment that did not occur or to inappropriatey cone notes diminishes the integrity and usefuness of the medica record. Providers are under pressure to see as many patients as possibe whie keeping the customer satisfied. It is important to remember that the primary function of an EHR is to manage data it does not repace compex decision-making or face-to-face contact with the patent. Whie taking advantage of time-saving features provided by an EHR might be tempting, the issue of patient safety shoud remain centra. Breach of Confidentiaity of Medica Information The breach of confidentiaity of medica information happens with paper medica records. EHRs, however, aow for a eve of breach that is inconceivabe at the paper-record eve. Case Study 5 An MA observed her sister-in-aw enter an examination room. Against cinic poicy, the MA accessed the patient s medica record and discovered that the patient had requested testing for sexuay transmitted diseases because she had a new sex partner. She aso earned that the patient was diagnosed with a sexuay transmitted disease. Later that week, the MA and her sister created a MySpace page that incuded the patient s picture and the sexuay transmitted disease information from her medica record. Discussion The foregoing case exampe was taken directy from a 2009 Minnesota Appeate Court opinion. It exempifies the ease with which a person with bad intentions can access an eectronic medica record and pubicize confidentia information. Even individuas with benign intentions technicay vioate patient privacy when they casuay browse through patient records for no medica purpose. Having a security poicy that incudes password usage is a first ine of defense against unauthorized access to patient medica information. Unfortunatey, a password aone does not protect confidentiaity when the password hoder is untrustworthy or has poor judgment. There is probaby no fai safe way to keep medica information confidentia, but there are ways to make it more difficut for cinicians and staff members to inappropriatey access information, incuding: 6 Add additiona ayers of access restrictions (for exampe, in addition to a password, the person accessing the record must have a particuar job or must be part of a particuar team of providers). Impement two-factor user authentication add a second, physica proof for access. (A bank ATM card is an exampe of a widey used form of two-factor authentication. It requires the combination of a PIN and a vaid card for access.) Put protocos in pace that define which staff members need access to the EHR and the eve of access that is appropriate. Do not aow password sharing. Change passwords frequenty. Review audit reports weeky or monthy to show who has accessed the medica records, during which hours and for which functions. Create a medica information confidentiaity poicy. Consistenty discipine peope who vioate confidentiaity poicies. Because technoogy continues to become more sophisticated, it is important to reguary reevauate the appicabiity of security protocos. Communicate reguary with vendors and IT staff to ensure state aw and HIPAA heath information confidentiaity compiance. 7 Caims Rx page 7

8 Curbside Consutations Emai conversations between providers add a new dimension to the risks associated with curbside consutations. Case Study A 64-year-od uninsured man was under the care of a famiy practitioner for mutipe heath issues, incuding an aortic murmur, high bood pressure, high choestero and diabetes. A CT scan reveaed an aortic thrombus. The physician emaied the scan and report to a friend who was a vascuar surgeon, asking for treatment recommendations. The surgeon recommended that an angiogram be performed to further evauate the thrombus. The physician repied back that the patient was uninsured and that an additiona test woud be too expensive. As an aternative, the surgeon suggested the patient be paced on warfarin. The physician cut and pasted the surgeon s recommendation from the ater emai into the patient s medica record. Based on the vascuar surgeon s recommendation, he initiated warfarin therapy at 2.5 mg per day. He conducted routine Prothrombin Time (PT) and Internationa Normaized Ratio (INR) testing. After five months of therapy, the patient s dose was set at 10 mg per day. One repeat CT scan was done after four months of therapy, reveaing that a thrombus was sti present at the same ocation. The patient coud not afford additiona testing, so the physician never ordered another CT scan. Two years after the patient had started on warfarin a series of unfortunate events ed to him dying shorty after being hospitaized for warfarin overdose. Discussion Paintiff s experts were critica of both the famiy practitioner and vascuar surgeon for the patient being paced on anticoaguation therapy without a forma consutation. They beieved that, at a minimum, a vascuar surgeon needed to review the patient s medica records and fims to give an opinion regarding the patient s condition. The vascuar surgeon had no idea that his casua recommendation woud become part of the patient s chart. It was additionay disturbing to find that his initia recommendation for an angiogram did not get pasted into the patient s chart. Risk Management Recommendations Formay consut with speciaists when necessary and document consutations in the patient's chart. Recognize that informa consutations are based on incompete information and take pace without the benefit of review or examination of the patient. Do not repace a forma consutation with a curbside consut. When emaiing coeagues, reaize that correspondence may become part of the patient s medica record. Labe the emai with a statement regarding whether you are providing a forma consutation. Inadequate EHR Training Inadequate training can increase iabiity risk, diminish patient safety, decrease productivity and resut in user frustration. Intensive training on the EHR is particuary important during transition from a paper record, but it is aso necessary on an ongoing basis to ensure user competency. As the foowing case shows, a heathcare entity must not ony ensure empoyee EHR competency, but it shoud aso ensure the EHR competency of independent contractors who use the system. Case Study On Juy 1, 2006, the patient, a 45-year-od man with a history of thyroid cancer, presented to the ED compaining of groin pain. A chest x-ray and a CT scan of the abdomen and pevis were ordered. Radioogist #1 reported that the chest x-ray showed a 3-4-mm noduar opacity in the eft upper obe of the ung, which he thought might be a sma granuoma. Radioogist #2 noted a 9-mm pumonary nodue in the eft ower obe of the ung on the CT Scan. Due to a series of miscommunications, these resuts were entered directy into the patient s eectronic record and his PCP was never informed of the resuts. Months ater, radioogist #3 interpreted another chest x-ray and noted a faint noduar density in the eft upper obe of the ung. Radioogist #3 thought this was equivoca and so informed the PCP. After speaking with radioogist #3, the PCP ogged onto the radioogy department s Web site. He brought up the patient s Juy 1 Caims Rx page 8

9 chest x-ray, but coud not see any irreguarities. He then attempted to access the Juy 1 abdomina CT images, but he had troube manipuating the icons. He was, however, abe to access the abdomina CT report. Because much of the upper obe overaps the ower obe, the PCP assumed that the nodue mentioned in the CT report was the upper obe density that radioogist #3 had tod him was equivoca. Three years ater the patient was diagnosed with ung cancer in the ower eft obe, where the density had been identified three years earier. Discussion This caim was compicated by the fact that the hospita was transitioning to an eectronic medica record system. Unfortunatey, the PCP did not obtain training on the system. His inabiity to fuy access his patient s information contributed to his faiure to adequatey foow up on the 2006 chest x-ray and CT scan resuts. Risk Management Recommendations Have a transition pan in pace that is reaistic and adequatey communicated to any provider who treats patients at your faciity or refers patients to your faciity for testing or treatment. Provide adequate training and technica support. m If providers are expected to use an eectronic medica record system, make avaiabe training opportunities with ongoing support. Ensure heathcare team member EHR proficiency. m Conduct audits and foow-up on identified weaknesses. m Provide refresher courses as necessary. Provide an environment where heathcare team members fee empowered to request assistance. Reguary assess and monitor errors and near misses. Evauate the cause of the probems and address them. 7 Faiure to Check EHR or Emai Inbox A probem minimay reated to the eectronics of communication, but more reated to an individua s persona practice, is not reguary checking one s EHR and emai inbox for test resuts. The issue is akin to not deaing with an inbox overfowing with paper. An interesting recent study found that having an EHR that deivers a test resuts via emai in offices without adequate foow-up processes actuay can increase the chance that a physician wi not receive significant resuts. In other words, in a paper-system office with inadequate foow-up processes, the chances of a test resut being noticed on a physician s desk are greater than are the chances of that test being discovered in a physician s EHR or emai inbox. 8 If your practice is using the EHR or emai for test resut deivery, it is important to have a poicy in pace that describes how frequenty providers must check their inboxes and the process by which resuts are then communicated to the various parties who need to see them. For a more detaied discussion about test resut communication, see the May 2009 Caims Rx entited Faiure to Appropriatey Communicate Abnorma Test Resuts, which is avaiabe on the NORCAL Web site at: may_09.pdf (accessed 8/25/2009). (continued on page 10) Caims Rx page 9

10 ( Faiure to Check EHR or Emai Inbox... continued from page 5) Patient-Physician Emai Correspondence Guideines The use of emai is becoming more common between providers and their patients. Various medica associations have pubished guideines for physician-patient eectronic communication. Incuded beow are a combined seection of emai correspondence recommendations from the American Medica Association and the Caifornia Medica Association:* Estabish a turnaround time for messages. Use an automatic repy function to acknowedge receipt of the patient s message and to warn patients against emaiing regarding urgent matters. Inform patients about the information privacy and security imitations of emai. Inform patients about who (other than the provider) is responding to emais. Retain and integrate eectronic and/or paper copies of emai communications with patients in their medica record. Estabish poicies that deineate the types of transactions (prescription refi, appointment scheduing, etc.) and sensitivity of subject matter (HIV, menta heath, etc.) that are permitted in emai correspondence. Te patients to indicate their main objective (e.g., prescription refi, biing issues) in the subject ine of the message. Instruct patients to incude their name, insurance pan, and patient identification number either in the subject ine or in the body of the message. Inform patients when their request has been competed. Instruct patients to use an autorepy feature to acknowedge receipt of the provider s message. Deveop emai retention, archiva and retrieva poicies and procedures. Do not send group maiings where recipients are visibe to each other; use a bind-copy emai function. End each emai message with the provider s fu name, contact information, reminders about medica information security and warnings about emai communication for emergencies. Request that patients send concise messages. If emai messages from a patient become engthy, confusing or if the correspondence is proonged, ask the patient to discuss the issue in person or on the teephone. Advise patients that abiding by the emai poicies is a condition of continued emai communication. Because emai becomes part of the medica record, and even if deeted it remains on the system, providers are encouraged to utiize the same conventions that woud be empoyed for any other patient communication. For exampe, avoid anger, sarcasm, harsh criticism, and ibeous references; use proper grammar; and check speing. Resources * AMA Guideines for Physician-Patient Eectronic Communications. Avaiabe on the AMA Web site at: member-groups-sections/young-physicians-section/advocacy-resources/guideines-physician-patient-eectronic-communications.shtm (accessed 8/24/2009). Physician Web sites, internet advice and emai. CMA On-Ca Document #0823. January Avaiabe on the Caifornia Medica Association Web site at: (accessed 8/24/2009). Caims Rx page 10

11 Turning Off the System s Warning Messages Case Study Isaac, et a. performed a retrospective anaysis of 233,537 medication safety aerts generated by 2,872 cinicians in Massachusetts, New Jersey, and Pennsyvania who used a common eectronic prescribing system. From January 1, 2006, through September 30, 2006, the system warned physicians neary 230,000 times about potentia drug interactions. Ninety percent of the time the physicians who received these warnings proceeded as if the aert had not appeared. 9 Discussion Most EHRs offer medication aerts. The objective of these aerts is to warn the person prescribing or ordering a medication of potentia adverse drug interactions, aergic reactions, etc. Unfortunatey, EHR aert technoogy has not deveoped to the point of fu utiity. As the study above indicates, a majority of physicians turn off or routiney override the aert function because it adds itte vaue to them or their patients. As the technoogy catches up to the needs of the peope who must use it, providers are encouraged to be cautious when disabing or overriding a system s aert functionaity. In the event of mapractice itigation arising from a medication error, the record of aerts that have been turned off or seectivey overridden may be difficut to expain to a judge or jury, especiay when heeding an ignored warning coud have prevented the patient s injury. 10 Risk Management Recommendations Work with vendors to create an aert system that is as usabe as possibe. Deveop a system of aerts that aows cinicians to determine their urgency and reevancy. Review which aerts are overridden and determine whether these need to be hard stops (aerts that cannot be overridden). Document the decision-making process. 7 If you do not use the aert system of an EHR, use an aternative system for determining whether the patient woud be exposed to aergy or drug interaction risks. Document the resut of your efforts. Faiure to Obtain Buy-in from Every Member of the Heathcare Team Some providers wi not make the change to EHR, regardess of the incentives offered or the penaties assessed. What is an individua decision for one, however, can affect an entire group s recordkeeping practice. There are vaid arguments on both sides of the EHR impementation debate, but if the impementation decision has been made and one or more providers refuse to use it, the issue cannot be ignored. Note-taking foowed by ater transcription can ead to deays and/or inaccuracies. Some practices have managed this situation by assigning a scribe to a physician who either cannot or wi not use an EHR. Athough this woud obviousy be an expensive way to manage the situation, it highights the fact that there are creative ways to work around buy-in probems. Concusion Because of the compexity of the many soutions and options avaiabe and the unique needs of each practice, panning, research and training are critica to the successfu conversion from paper to eectronic records. Providers are encouraged to impement and appropriatey update poicies and procedures that address the iabiity and patient safety risks that are particuar to these new and constanty improving technoogies, whie continuing to appy risk management strategies that have been effective in a paper-based system. Caims Rx page 11

12 CPOE (Computerized Physician Order Entry) Risks Identified in a Recent Study A 2005 JAMA artice discusses a study that focused on medication errors faciitated by CPOE in a major urban tertiary-care teaching hospita with 750 beds, 39,000 annua discharges, and a widey used CPOE system operationa there from 1997 to The authors found that the CPOE system at this hospita faciitated 22 types of medication errors, as iustrated by the foowing: Physicians reied on the CPOE dispays to determine the minima effective or usua doses, but those doses were based on the pharmacy s warehousing and purchasing decisions, not on cinica guideines. For exampe, where a usua dosage was 20 or 30 mg, the pharmacy woud stock 10-mg doses, which resuted in 10-mg units being dispayed on the CPOE screen. Physicians then ordered 10-mg doses for patients, mistakeny beieving that it was the usua dosage. Physicians ordered increased or decreased doses of medications without discontinuing current dose because they mistakeny beieved that ordering the new dose woud automaticay discontinue the current dose in the system. Physicians ordered medications that were associated with a particuar procedure or test, but if the procedure or test was canceed, the system did not automaticay cance the medication. Consequenty, patients received unnecessary medications. Because medication charting was cumbersome and the screen dispays were fragmented, immediate orders and give as needed medications (P.R.N.) were often not entered into the system and not canceed as directed. This resuted in patients receiving unintended doses. Because reapprova stickers were paced in the paper chart and physicians primariy used the CPOE to order antibiotics, unintentiona gaps occurred in patient antibiotic therapy. The CPOE required physicians to identify diuents for administering antibiotics, but the physicians were not aware of interactions between some diuents and antibiotics. This generated precipitates and other probems. Aergy information was deayed because physicians ignored warnings and depended on pharmacists for checking drug aergies. Physicians seected the wrong patient record because the names were cose together, the font was sma, every screen did not contain the patient s name and patients were isted aphabeticay, instead of by teams or rooms. The wrong medication was ordered because the patient s medication information was not synthesized on one screen. Getting a of the medication information sometimes necessitated going through 20 screens. Because a physician was not ogged out of a patient s record, the patient whose record was sti active got a medication intended for a different patient. Because the EHR canceed preoperative orders and required numerous steps to activate orders foowing surgery, postsurgica medication was deayed. Caims Rx page 12

13 CPOE (Computerized Physician Order Entry) Risks Identified in a Recent Study (continued) Because of system crashes and maintenance, drug ordering was deayed. If a patient was moved whie the system was down, medications went to the new patient in the patient s former room. A cumbersome interface made contemporaneous drug administration recording difficut, resuting in drug administration being charted at the end of the shift and consequenty providing physicians with inaccurate information about when the medication was administered. Based on their findings, the authors made the foowing recommendations: Do not direct cinica actions with CPOE if it causes patient care to deteriorate. Examine the technoogy to determine if it is working effectivey. Fix the technoogy if it is counterproductive. When a medication error occurs, ook for the weakness in the way the system works instead of assuming the error was the resut of human error. Expect and pan for revisions and quaity improvement. Reference Koppe R., et a. Roe of Computerized Physician Order Entry Systems in Faciitating Medication Errors. JAMA. 2005;293(10): Endnotes 1 Leape LL, Bates DW, Cuen DJ, et a. Systems anaysis of adverse drug events. JAMA. 1995;274: Varkey P, Cunningham J, Bisping S. Improving Medication Reconciiation in the Outpatient Setting. The Joint Commission Journa on Quaity and Patient Safety. May Voume 33 Number 5. 3 Case study based on Tempated Charting The Sippery Sope to Frauduent Documentation, Friday, October 12, Avaiabe on the ERMurse Bog at : (accessed 8/24/2008). 4 Compiance Risks Grow with Eectronic Medica Record Systems. (accessed 8/24/2009). 5 Case study based on Yath vs. Fairview Cinics, et a. 767 N.W.2d 34; 2009 Minn. App. LEXIS 117 (2009). 6 HIPAA Security Guidance for Remote Use. Avaiabe on the U.S. Department of Heath and Human Services Web site at: (accessed 8/24/2009). 7 Safey impementing heath information and converging technoogies. Sentine Event Aert 42, December 11, Avaiabe on the Joint Commission Web site at: (accessed 8/24/2009). 8 Casaino R, et a. Frequency of Faiure to Inform Patients of Cinicay Significant Outpatient Test Resuts. Arch Intern Med. 2009;169(12): Isaac T, Weissman S, Davis R, Massagi, Cyruik A, Sands D, Weingart S. Overrides of Medication Aerts in Ambuatory Care. Arch Intern Med. 2009;169(3): Shay E. Eectronic heath records in itigation. Pubished September Avaiabe on the Physician s News Digest Web site at: (accessed 8/24/2009). Caims Rx page 13

14 A Bright Invention from NORCAL Introducing MyCME from NORCAL Mutua. Review our wide array of risk management resources and services. Register for and compete CME courses at your convenience. Submit your Attestation Form onine. Print transcripts and certificates everything from one easy-to-navigate website. Our passion protects your practice Learn more at or ca , ext 2244.

15 560 Davis Street, Suite 200 San Francisco, CA Prsrt. Std U.S. Postage PAID Permit #751 San Diego Inside... Eectronic Heath Records: Recognizing and Managing the Risks Caims cinica & risk management perspectives October 2009 New CME Podcast avaiabe at Now you can earn CME credit wherever you are with Compex Regiona Pain Syndrome a new CME podcast avaiabe excusivey from NORCAL Mutua. Go to and cick on podcast to downoad and isten to this new CME activity NORCAL Mutua Insurance Company. Reproduction permissibe with written permission and credit. Direct inquiries to: NORCAL Mutua Insurance Company Risk Management Department 560 Davis Street, Suite 200 San Francisco, CA (800) The information in this pubication is obtained from sources generay considered to be reiabe; however, accuracy and competeness are not guaranteed. The information is intended as risk management advice. It does not constitute a ega opinion, nor is it a substitute for ega advice. Lega inquiries about topics covered in this pubication shoud be directed to your attorney. Guideines and/or recommendations contained in this pubication are not intended to determine the standard of care, but are provided as risk management advice. Guideines presented shoud not be considered incusive of a proper methods of care or excusive of other methods of care reasonaby directed to obtain the same resuts. The utimate judgment regarding the propriety of any specific procedure must be made by the physician in ight of the individua circumstances presented by the patient. Visit NORCAL Mutua on the Internet at 687J-RM

16 Caims Rx Evauation and CME Attestation Form Eectronic Heath Records: Recognizing and Managing the Risks Reease Date: October 2009 Expiration Date: October 31, 2010 In order to receive CME credit,* you must fi out this form in its entirety and return it to NORCAL Mutua by the expiration date above. For instant access to your CME certificate, go to og-in to MyNORCAL and cick on MyCME. You may access this enduring materia and submit the form eectronicay. Aternativey, you can mai or fax this (paper) form to receive your CME certificate in 7-10 business days. Name: Address: Phone: Emai: NORCAL Mutua poicy number (Required for CME credit): *Receipt of CME credit is imited to NORCAL poicyhoders. Target Audience: A providers. 1. Educationa Outcomes: Overa, degree to which the materia presented is appicabe in your practice setting: Not appicabe Very appicabe 2. Appication of Risk Management Strategies By providing risk management and patient safety-based strategies, this CME activity is designed to reduce your risk exposure associated with the impementation and utiization of an EHR system. To demonstrate your abiity to appy or utiize the risk management recommendations herein, pease seect the strategies you pan to impement or currenty utiize in your practice (mark the box yes or no for each): Risk Management Strategies Yes No Ensure you/your staff members and cinicians are aware of and abide by EHR poicies and procedures. In emai exchanges with patients and other providers, utiize proper grammar and punctuation and avoid anguage that is not considered appropriate within physician/patient communications. Remain vigiant regarding patient foow-up; do not rey soey upon EHR features. Review records for accuracy, paying specia attention to possibe errors reated to auto-popuate features. Work with your EHR vendor to design an aert system that is meaningfu, and one that minimizes inappropriate or fase aerts that might condition users to routiney override or ignore warnings. 3. Other Strategies to Minimize Risk The October Caims Rx focuses on the physician risks associated with the use of an EHR system. Risks that can be associated with the use of an EHR system incude: inaccurate data entry; unauthorized access; disregard of warnings; iabiity via emai consutations; inadequate training; and faiure to foow up on abnorma ab vaues. Recognizing that physician users pay an integra part in the success of an EHR system, we addressed the risk areas of communication, foow-up and documentation at the provider eve. However, system changes that promote quaity and risk management must take pace as we for the physician behaviora change to continue successfuy. For additiona information, pease visit our Web site at or contact the Risk Management Department at (800) , ext Was this activity free of commercia bias? Yes No CME Attestation I attest that I participated in this CME activity and caim credits (use quarter hour increments) of AMA PRA Category 1 Credit TM up to a maximum of one credit (hour). Signature Date (mm/dd/yy) You may submit this form onine at Or you can mai or fax it to: Attention: Risk Management, NORCAL Mutua Insurance Company, 560 Davis Street, Suite 200, San Francisco, CA 94111, Fax: (415)

A guide to listing on the London Stock Exchange

A guide to listing on the London Stock Exchange A guide to isting on the London Stock Exchange Pubished by White Page Ltd in association with the London Stock Exchange, with contributions from: Pubishing editor: Nige Page Pubisher: Tim Dempsey Design:

More information

How to Make Adoption an Affordable Option

How to Make Adoption an Affordable Option How to Make Adoption an Affordabe Option How to Make Adoption an Affordabe Option 2015 Nationa Endowment for Financia Education. A rights reserved. The content areas in this materia are beieved to be current

More information

Tackling external fraud

Tackling external fraud Good practice in tacking externa fraud Xxxxxxxxxxx GOOD PRACTICE GUIDE Tacking externa fraud Good practice in tacking externa fraud Xxxxxxxxxxx The Nationa Audit Office scrutinises pubic spending on behaf

More information

Health Literacy Online

Health Literacy Online Heath Literacy Onine A guide to writing and designing easy-to-use heath Web sites Strategies Actions Testing Methods Resources HEALTH OF & HUMAN SERVICES USA U.S. Department of Heath and Human Services

More information

All Aspects. of a...business...industry...company. Planning. Management. Finance. An Information. Technical Skills. Technology.

All Aspects. of a...business...industry...company. Planning. Management. Finance. An Information. Technical Skills. Technology. A Aspects Panning of a...business...industry...company Management Finance Technica Skis Technoogy Labor Issues An Information Sourcebook Community Issues Heath & Safety Persona Work Habits Acknowedgement

More information

Example of Credit Card Agreement for Bank of America Visa Signature and World MasterCard accounts

Example of Credit Card Agreement for Bank of America Visa Signature and World MasterCard accounts Exampe of Credit Card Agreement for Bank of America Visa Signature and Word MasterCard accounts PRICING INFORMATION Actua pricing wi vary from one cardhoder to another Annua Percentage Rates for Purchases

More information


YOUR MOTORCYCLE POLICY BOOKLET YOUR MOTORCYCLE POLICY BOOKLET 2013 CAR INSURANCE Our Poicy gives you 5 Star Protection Hastings Direct and Premier motorcyce insurance poicies have been awarded a 5 Star Rating from Defaqto, the independent

More information


CENTER START-UP MANUAL COMMUNITY TECHNOLOGY CENTERS NETWORK CENTER START-UP MANUAL With Support From: Nationa Science Foundation U.S. Department of Housing & Urban Deveopment Surdna Foundation Community Technoogy Centers Network

More information

NorthSTAR MEMBER INFORMATION AND PROVIDER DIRECTORY. Libro de Miembros y Directorio de Proveedores

NorthSTAR MEMBER INFORMATION AND PROVIDER DIRECTORY. Libro de Miembros y Directorio de Proveedores Si necesita esta información en españo soamente, por favor ame: 1-888-800-6799 For: En os Condados: Coin, Daas, Eis, Hunt, Kaufman, Navarro and Rockwa Counties If your Provider is not isted, pease ca:

More information

Securing the future of excellent patient care. Final report of the independent review Led by Professor David Greenaway

Securing the future of excellent patient care. Final report of the independent review Led by Professor David Greenaway Securing the future of exceent patient care Fina report of the independent review Led by Professor David Greenaway Contents Foreword 3 Executive summary 4 Training structure for the future 6 Recommendations

More information

Are Health Problems Systemic?

Are Health Problems Systemic? Document de travai Working paper Are Heath Probems Systemic? Poitics of Access and Choice under Beveridge and Bismarck Systems Zeynep Or (Irdes) Chanta Cases (Irdes) Meanie Lisac (Bertesmann Stiftung)

More information

Use R! Series Editors: Robert Gentleman Kurt Hornik Giovanni G. Parmigiani. For further volumes: http://www.springer.

Use R! Series Editors: Robert Gentleman Kurt Hornik Giovanni G. Parmigiani. For further volumes: http://www.springer. Use R! Series Editors: Robert Genteman Kurt Hornik Giovanni G. Parmigiani For further voumes: http://www.springer.com/series/6991 Graham Wiiams Data Mining with Ratte and R The Art of Excavating Data

More information

Your car insurance policy booklet. This booklet includes your policy wording, so keep it safe in case you need it.

Your car insurance policy booklet. This booklet includes your policy wording, so keep it safe in case you need it. Your car insurance poicy booket This booket incudes your poicy wording, so keep it safe in case you need it. Contents FAQs 2 Am I covered for theft if I eave my car unocked? 2 How much wi you pay if my

More information

Relationship Between the Retirement, Disability, and Unemployment Insurance Programs: The U.S. Experience

Relationship Between the Retirement, Disability, and Unemployment Insurance Programs: The U.S. Experience Reationship Between the Retirement, Disabiity, and Unempoyment Insurance Programs The US Experience by Virginia P Reno and Danie N, Price* This artice was prepared initiay for an internationa conference

More information

Diploma Decisions for Students with Disabilities. What Parents Need to Know

Diploma Decisions for Students with Disabilities. What Parents Need to Know Dipoma Decisions for Students with Disabiities What Parents Need to Know Forida Department of Education Bureau of Exceptiona Education and Student Services Revised 2005 This is one of many pubications

More information

RESIDENCE YOUR CONTRACT WITH US 2014/2015. residenceatwestern.ca 2012 / 2013 RESIDENCE HANDBOOK. Residence Handbook. and Understandings

RESIDENCE YOUR CONTRACT WITH US 2014/2015. residenceatwestern.ca 2012 / 2013 RESIDENCE HANDBOOK. Residence Handbook. and Understandings YOUR CONTRACT WITH US RESIDENCE residenceatwestern.ca 2014/2015 2012 / 2013 RESIDENCE HANDBOOK Residence Handbook AND UNDERSTANDINGS and Understandings Wecome Home Bring this handbook with you to residence!

More information

YOUR GUIDE TO Healthy Sleep

YOUR GUIDE TO Healthy Sleep YOUR GUIDE TO Heathy Seep Your Guide to Heathy Seep NIH Pubication No. 11-5271 Originay printed November 2005 Revised August 2011 Contents Introduction...1 What Is Seep?...4 What Makes You Seep?...7

More information

Internal Control. Guidance for Directors on the Combined Code

Internal Control. Guidance for Directors on the Combined Code Interna Contro Guidance for Directors on the Combined Code ISBN 1 84152 010 1 Pubished by The Institute of Chartered Accountants in Engand & Waes Chartered Accountants Ha PO Box 433 Moorgate Pace London

More information

Space for People. Targeting action for woodland access

Space for People. Targeting action for woodland access Space for Peope Targeting action for woodand access Contents Summary 2 Section 1 Context 3 The Woodand Trust 3 The case for accessibe woodand 3 Section 2 Deveoping targets 6 Woods for Peope 6 The Woodand

More information

TMI ING Guide to Financial Supply Chain Optimisation 29. Creating Opportunities for Competitive Advantage. Section Four: Supply Chain Finance

TMI ING Guide to Financial Supply Chain Optimisation 29. Creating Opportunities for Competitive Advantage. Section Four: Supply Chain Finance TMI171 ING info pat :Info pat.qxt 19/12/2008 17:02 Page 29 ING Guide to Financia Suppy Chain Optimisation Creating Opportunities for Competitive Advantage Section Four: Suppy Chain Finance Introduction

More information

Advancing Healthy Adolescent Development and Well-Being. n Charlyn Harper Browne, PhD n

Advancing Healthy Adolescent Development and Well-Being. n Charlyn Harper Browne, PhD n Advancing Heathy Adoescent Deveopment and We-Being n Charyn Harper Browne, PhD n SEPTEMBER 2014 Youth Thrive: Advancing Heathy Adoescent Deveopment and We-Being 2014, Center for the Study of Socia Poicy

More information

Old Threat, New Approach: Tackling the Far Right Across Europe

Old Threat, New Approach: Tackling the Far Right Across Europe Od Threat, New Approach: Tacking the Far Right Across Europe GUIDE FOR POLICY MAKERS With the financia support from the Prevention of and Fight Against Crime Programme of the European Union European Commission

More information

Project Stories from the CENTRAL EUROPE Programme Environmental Risk Management and Climate Change

Project Stories from the CENTRAL EUROPE Programme Environmental Risk Management and Climate Change Project Stories from the CENTRAL EUROPE Programme Environmenta Risk Management and Cimate Change Pubisher: CENTRAL EUROPE Programme Joint Technica Secretariat Museumstrasse 3/A/III 1070 Vienna Austria

More information

OPINION Two cheers for P-values?

OPINION Two cheers for P-values? Journa of Epidemioogy and Biostatistics (2001) Vo. 6, No. 2, 193 204 OPINION Two cheers for P-vaues? S SENN Department of Epidemioogy and Pubic Heath, Department of Statistica Science, University Coege

More information

improving culture, arts and sporting opportunities through planning a good practice guide

improving culture, arts and sporting opportunities through planning a good practice guide improving cuture, arts and sporting opportunities through panning a good practice guide Improving Cuture, Arts and Sporting Opportunities through Panning. A Good Practice Guide Supported by: A fu ist of

More information

275 Tips About Medical Records: A Guide for Legal Nurse Consultants

275 Tips About Medical Records: A Guide for Legal Nurse Consultants 275 Tips About Medical Records: A Guide for Legal Nurse Consultants Pat Iyer, MSN, RN, LNCC The Pat Iyer Group, LLC 908-237-0278 The Pat Iyer Group Pat Iyer The Pat Iyer Group, LLC. 260 Route 202/31, Suite

More information

The IBM System/38. 8.1 Introduction

The IBM System/38. 8.1 Introduction 8 The IBM System/38 8.1 Introduction IBM s capabiity-based System38 [Berstis 80a, Houdek 81, IBM Sa, IBM 82b], announced in 1978 and deivered in 1980, is an outgrowth of work that began in the ate sixties

More information

Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide. Peggy Evans, PhD, CPHIT Qualis Health Seattle, Washington

Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide. Peggy Evans, PhD, CPHIT Qualis Health Seattle, Washington Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide July 2012 Prepared by: Jeff Hummel, MD, MPH Qualis Health Seattle, Washington Peggy Evans, PhD, CPHIT Qualis Health Seattle,

More information

Childhood Lead Poisoning

Childhood Lead Poisoning Chidhood Lead Poisoning Chidhood Lead Poisoning WHO Library Cataoguing-in-Pubication Data Chidhood ead poisoning. 1.Lead poisoning - etioogy. 2.Lead poisoning - prevention and contro. 3.Chid. 4.Infant.

More information

Design of Follow-Up Experiments for Improving Model Discrimination and Parameter Estimation

Design of Follow-Up Experiments for Improving Model Discrimination and Parameter Estimation Design of Foow-Up Experiments for Improving Mode Discrimination and Parameter Estimation Szu Hui Ng 1 Stephen E. Chick 2 Nationa University of Singapore, 10 Kent Ridge Crescent, Singapore 119260. Technoogy

More information