Patient Safety Using Electronic Healthcare Records & Innovation Adoption in the Emergency Department

Transcription

1 Patient Safety Using Electronic Healthcare Records & Innovation Adoption in the Emergency Department Christopher 'Toff' Peabody, MD, MPH Emergency Physician & Clinical Assistant Professor, University of California, San Francisco LEADING INNOVATION IN PATIENT SAFETY

2 Patient Safety and HIT in the Emergency Department Christopher R. Peabody, MD, MPH Assistant Clinical Professor University of California, San Francisco

3 Objectives Awareness: learn the unique factors that predispose the ED for HIT related errors Accountability: errors related to HIT follow a socio-technical framework Abilities: Apply HIT innovations to improve ED work-flow Actions: implement a Dream Team program to improve culture and communication

4 The ED is a Special Place The Emergency Department is a kind of sanctuary where people come when they are cold, tired, hungry or sick. ---Ed Newton, Chairman LAC+USC

5 The ED is High Risk Emergency Departments: Initiate most critical care in the hospital Responsible for over 2/3 of hospital admissions Have rapid turnover and constant interruptions Contain unfamiliar teams and unfamiliar patients 1. Farley HL, Baumlin KM, Hamedani AG, Cheung DS, Edwards MR, Fuller DC, Genes N, Griffey RT, Kelly JJ, McClay JC, Nielson J, Phelan MP, Shapiro JS, Stone-Griffith S, Pines JM. Quality and safety implications of emergency department information systems. Ann Emerg Med Oct;62(4):

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7 Can innovations in Health Information Technology ensure that the Emergency Department is a highly reliable environment? y-e.html and_safety_improvement/improving_safety-e.html

8 Lets Start with a Case September 25, 2014 Dallas, Tx Mr. Duncan arrived in ED with dizziness, abdominal pain, headache, and fever Received a separate nursing and physician assessment His recent travel from Liberia is noted in the electronic health record Blood work, CT Head / abdomen Patient is discharged home Cortise et al. Expert Panel Report to Texas Health Resources Leadership on the 2014 Ebola Events

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10 Expert Panel Report Take aways from first ED visit Inadequate communication and over-reliance on EHR to convey critical information Travel history not included on the standard assessment screen of EHR, no decision support It appears that technology may have displaced good team practice Cortise et al. Expert Panel Report to Texas Health Resources Leadership on the 2014 Ebola Events

11 Poorly designed Health-IT was partially responsible for this national event Hamon Tower Texas Health Presbyterian Emergency Department Dallas Third Floor Ambulance Bays Waiting Room =WhatsNext&version=WhatsNext&contentID=WhatsNext&moduleDetail= undefined&pgtype=multimedia

12 We Must Ask Does Health-IT Provide: The Right Information At the Right Time To Make the Right Decisions?

13 1. ECRI. Top 10 Patient Safety Concerns for Healthcare Organizations. Plymouth Meeting (PA): ECRI Institute; 2015 Apr. Available at 2. ECRI. Top 10 Health Technology Hazards for Plymouth Meeting (PA): ECRI Institute; 2014 Nov. Available at Hazards.aspx..

14 ECRI Institute s Top 10 Patient Safety Concerns and Top 10 Health Tech Hazards for 2015 ECRI Institute s Top 10 Patient Safety Concerns for 2015 ECRI Institute s Top 10 Health Technology Hazards for out of 10 safety concerns are health technology hazards!

15 Patient Harm related to Health-IT is Rarely a Hardware Problem

16 Health-IT Related Harm Health-IT related patient harm stems from: Human-computer interface Work-flow and communication Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care 2010;19(Suppl 3):i68 74.

17 Human-Computer Interface Juxtaposition Errors Unintended patient order / documentation Incorrect medication (look alike / sound alike) Poor Data Display The output of patient record is virtually unreadable Critical information not easily accessible 1. Handel DA, Wears RL, Nathanson LA, Pines JM. Using information technology to improve the quality and safety of emergency care. Acad Emerg Med Jun;18(6):e Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293:

18 Work-flow and Communication Communication failure Ironic given legibility improvement Physicians and Nurses retreating to different parts of the ED Alert Fatigue Alerts similar / same regardless of relevance 2,700 warnings for 1 severe drug event 1. Farley HL, Baumlin KM, Hamedani AG, Cheung DS, Edwards MR, Fuller DC, Genes N, Griffey RT, Kelly JJ, McClay JC, Nielson J, Phelan MP, Shapiro JS, Stone-Griffith S, Pines JM. Quality and safety implications of emergency department information systems. Ann Emerg Med Oct;62(4): Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care 2010;19(Suppl 3):i68 74.

19 Health IT Cannot Displace Team Practice

20 Emergency department physicians spent 44 percent of their time entering data into electronic medical records, clicking up to 4,000 times during a 10-hour shift. -- Becker s Health IT and CIO Review magazine

21 Health IT is Ripe for Innovation

22 Innovations New mechanisms To encourage feedback about ongoing Health- IT safety issues Red Cover Reports Establish a HIT Safety Center Conflicts of interest are holding back a more rigorous approach to identifying and regulating software problems Source: Tahir D. Feds criticized for lax oversight of health IT. Modern Healthcare 2015 Apr 4. Available at

23 ED is a Place of Transition Disaster Response Radiology Inpatient Floor Emergency Department Home SNF/Hospice OR Cath Lab IR

24 Innovations Health-IT safe Transition Home Video Discharge Instructions Text Message Check-in / Appointment Reminders Telemedicine Follow-up Caregiver engagement

25 Innovations Communication Changing Culture Supporting unfamiliar teams Preventing burnout

26 Example: Physician Training Compassionate, Idealistic Students Crucible of Residency Burnt-out Attending Physician 1. Shanafelt TD, Balch CM, Bechamps G, et al. Burn- out and medical errors among American surgeons. Ann Surg 2010;251: Wallace JE, Lemaire J. Physician well being and quality of patient care: an exploratory study of the missing link. Psychol Health Med 2009;14:

27 Does physician training reflect the workforce culture of patient safety that we need in our physician leaders?

28 Peer-to-Peer Mentorship What if each resident had their own personal board of directors? Small Groups of 4-5 to hold each other accountable for their dreams Christopher R. Peabody and Jan Shoenberger (2013) Dream Teams -- A Peer-to-Peer Mentorship Program for Adult Learners in an Emergency Medicine Residency Training Program. Innovations in Medical Education Conference 2014.

29 Dream Team Program Director Chief Resident Chief Resident Chief Resident Chief Resident

30 Dream Team Pilot Impact: Discuss shared strategies for work-life balance Utilize network of peers for career development Discuss resident research project Discuss medical errors amongst peers Kimo Takayesu J, Ramoska EA, Clark TR, Hansoti B, Dougherty J, Freeman W, Weaver KR, Chang Y, Gross E. Factors Associated With Burnout During Emergency Medicine Residency. Acad Emerg Med Sep;21(9):

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32 Conclusions Health-IT Related Patient Harm in the ED Human-computer Interface Work-flow and communications Culture and Teams keep patients safe

33 Conclusions Innovation in Health-IT Red Cover Reports Community of Practice Enable work-flow in the hospital Use technology to make patient transitions safer

34 References Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293: Magrabi F, Aarts J, Nohr C, et al. A comparative review of patient safety initiatives for national health information technology. Int J Med Inform 2013;82:e Walker JM, Carayon P, Leveson N, et al. EHR safety: the way forward to safe and effective systems. J Am Med Inform Assoc 2008;15: Meeks DW, Smith MW, Taylor L, et al. An analysis of electronic health record-related patient safety concerns. J Am Med Inform Assoc 2014;21: Sittig DF, Classen DC, Singh H. Patient safety goals for the proposed Federal Health Information Technology Safety Center. J Am Med Inform Assoc 2015;22: Wright A, Henkin S, Feblowitz J, et al. Early results of the meaningful use program for electronic health records. N Engl J Med 2013;368: Patient Safety Advisory Group. Safe use of health information technology Sentinel Event Alert #54. The Joint Commission Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care 2010;19(Suppl 3):i Sittig DF, Singh H. Electronic health records and national patient-safety goals. N Engl J Med 2012;367: Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. J Am Med Inform Assoc 2013;20: Sittig DF, Singh H. A red-flag-based approach to risk management of EHR-related safety concerns. J Healthc Risk Manag 2013;33:21 6. Sittig DF, Ash JS, Singh H. The SAFER guides: empowering organizations to improve the safety and effectiveness of electronic health records. Am J Manag Care 2014;20: Koppel R. Monitoring and evaluating the use of electronic health records. JAMA 2010;303:

35 References Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care--an interactive sociotechnical analysis. J Am Med Inform Assoc Sep-Oct;14(5): Farley HL, Baumlin KM, Hamedani AG, Cheung DS, Edwards MR, Fuller DC, Genes N, Griffey RT, Kelly JJ, McClay JC, Nielson J, Phelan MP, Shapiro JS, Stone-Griffith S, Pines JM. Quality and safety implications of emergency department information systems. Ann Emerg Med Oct;62(4): Shanafelt TD, Balch CM, Bechamps G, et al. Burn- out and medical errors among American surgeons. Ann Surg 2010;251: Wallace JE, Lemaire JB, Ghali WA. Physician well- ness: a missing quality indicator. Lancet 2009;374: Wallace JE, Lemaire J. Physician well being and quality of patient care: an exploratory study of the missing link. Psychol Health Med 2009;14: Prins JT, Gazendam-Donofrio SM, Tubben BJ, van der Heijden FM, van de Wiel HB, Hoekstra-Weebers JE. Burnout in medical residents: a review. Med Educ 2007;41: Kimo Takayesu J, Ramoska EA, Clark TR, Hansoti B, Dougherty J, Freeman W, Weaver KR, Chang Y, Gross E. Factors Associated With Burnout During Emergency Medicine Residency. Acad Emerg Med Sep;21(9): Bill George and Doug Baker, True North Groups: A Powerful Path to Personal and Leadership Development. Berrett-Koehler Publishers (September 1, 2011). ACGME Emegency Medicine Program Requirements (07/01/2013), Requirments: IV.A.5.c).(1), IV.A.5.c).(2), IV.A.5.d).(2), IV.A.5.d).(3) Thomas NK. Resident burnout. JAMA (23): Reichheld, Frederick F. (December 2003). "One Number You Need to Grow".Harvard Business Review.

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37 Innovative Solutions The three ED Mantras for pre-shift team-up Keep our patients safe Get each others back Have the shift of our lives