How does your EHR tie into Patient Safety? 2 nd Annual Wyoming Patient Safety Summit Casper, Wyoming November 15, 2013 David S Hanekom, M.D., F.A.C.P., C.M.P.E Chief Medical Officer MDdatacor, Inc.
The Challenge First, do no harm is the first principle of medicine and the first thought in every health care provider s mind when treating patients. Increasingly, we are coming to learn that our health care system does not always meet patients needs in that respect. In Wyoming, this hits even more close to home, because our patients are not anonymous statistics; they are our neighbors, friends, and co-workers. Patient safety is receiving increased attention as the result of federal health care reform and a growing movement among health care professionals, patients and others to improve patient safety, both as a way of reducing cost and simply because it s the right thing to do. www.wyomed.org
The Environment > 70% of providers using basic EHR s The healthcare industry, with the federal government at the helm, is setting sail on a voyage into the unknown: whether and to what extent patients are suffering harm from the systems that providers have spent many billions of dollars buying, and the feds many billions in incentivizing. That's the part we don't know, said Dr. Ron Wyatt, medical director, division of healthcare improvement at the Joint Commission. We know that probably less than 10% of adverse events are reported. That's how big the water is.
Slide 7 of 23 Safety as a system property Safety is a characteristic of a sociotechnical system System-level failures occur almost always because of unforeseen combinations of component failures
EMR and Patient Safety Events The two researchers obtained patient outcome data on 35 million enrollees in employersponsored benefit plans for large employers in all 50 States. This included information on claims for inpatient and outpatient care and prescription drugs. They also used an information technology database to obtain EMR data on 92,853 non-elderly adults undergoing major surgeries at 2,619 hospitals. Annual hospital survey data were used to determine hospital characteristics. Nearly 21 percent of surgeries were performed in hospitals with basic EMRs. Overall, 5 percent of the surgeries resulted in at least 1 of 24 potentially preventable adverse medical events. No differences in the rates of patient safety events were observed between EMR and non-emr hospitals. However, EMR hospitals spent less on a patient safety event ($55,810) than non-emr hospitals ($60,093). Also, in EMR hospitals, deaths after patient safety events were reduced by 34 percent and hospital readmissions by 39 percent. Additional research is needed to determine why EMRs do not prevent patient safety events, but do reduce negative outcomes once they occur. Internet Citation: Electronic medical records reduce negative outcomes and related costs after patient safety events occur: Research Activities, October 2012, No. 386. October 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsletters/research-activities/oct12/1012ra12.html
Medication Alerts use in Ambulatory Care 6.6 % 0f electronic prescriptions generated medication safety alerts Clinicians accepted 9.2% of drug interaction alerts and 23% of allergy alerts High-severity alerts were accepted slightly more often (10.4% v. 7.1%) than low-severity alerts No difference in alert acceptance between clinicians of different specialties CONCLUSION: Clinicians override most medication alerts, suggesting that current medication alerts may be inadequate to protect patient safety. Arch Intern Med. 2009 Feb 9;169(3):305-11. doi: 10.1001/archinternmed.2008.551. Overrides of medication alerts in ambulatory care. Isaac T, Weissman JS, Davis RB, Massagli M, Cyrulik A, Sands DZ, Weingart SN.
CPOE- Unintended Consequences More/New work for clinicians Clinical workflow mismatch Never ending system demands Problems related to paper persistence Changes in communication patterns and practices Generation of new kinds of errors Overdependence on technology www.cpoe.org
ERRORS RELATED TO DEFAULT VALUES Pennsylvania Patient Safety Authority Examines Electronic Health Record (EHR) Errors Related to Default Values The data analysis gives Pennsylvania healthcare facilities information they can use to avoid these types of errors when using EHRs HARRISBURG: Over 300 events related to EHR software defaults analyzed by the Pennsylvania Patient Safety Authority gives Pennsylvania healthcare facilities information they can use to avoid EHR events such as wrong-time and wrongdose errors. The information was published in the September issue of the Pennsylvania Patient Safety Advisory released today. Default values are often used to add standardization and efficiency to hospital information systems, Erin Sparnon, MEng, patient safety analyst for the Pennsylvania Patient Safety Authority said. For example, a healthy patient using a pain medication after surgery would receive a certain medication, dose and delivery of the medication already preset by the healthcare facility within the EHR system for that type of surgery. www.patientsafetyauthority.org; accessed 11/11/2013
Pa Patient Saf Advis 2012 Dec;9(4):113-21. Role of EHR in Patient Safety Events
PATIENT SAFETY/CONCEPTS Quality and Safety Implications of Emergency Department Information Systems Heather L. Farley, MD; Kevin M. Baumlin, MD; Azita G. Hamedani, MD, MPH; Dickson S. Cheung, MD, MBA; Michael R. Edwards, MD; Drew C. Fuller, MD, MPH; Nicholas Genes, MD, PhD; Richard T. Griffey, MD, MPH; John J. Kelly, DO; James C. McClay, MS, MD; Jeff Nielson, MD, MS; Michael P. Phelan, MD; Jason S. Shapiro, MD; Suzanne Stone-Griffith, RN, MSN; Jesse M. Pines, MD, MBA The Health Information Technology for Economic and Clinical Health Act of 2009 and the Centers for Medicare & Medicaid Services meaningful use incentive programs, in tandem with the boundless additional requirements for detailed reporting of quality metrics, have galvanized hospital efforts to implement hospital-based electronic health records. As such, emergency department information systems (EDISs) are an important and unique component of most hospitals electronic health records. System functionality varies greatly and affects physician decisionmaking, clinician workflow, communication, and, ultimately, the overall quality of care and patient safety. This article is a joint effort by members of the Quality Improvement and Patient Safety Section and the Informatics Section of the American College of Emergency Physicians. The aim of this effort is to examine the benefits and potential threats to quality and patient safety that could result from the choice of a particular EDIS, its implementation and optimization, and the hospital s or physician group s approach to continuous improvement of the EDIS. Specifically, we explored the following areas of potential EDIS safety concerns: communication failure, wrong order wrong patient errors, poor data display, and alert fatigue. Case studies are presented that illustrate the potential harm that could befall patients from an inferior EDIS product or suboptimal execution of such a product in the clinical environment. The authors have developed 7 recommendations to improve patient safety with respect to the deployment of EDISs. These include ensuring that emergency providers actively participate in selection of the EDIS product, in the design of processes related to EDIS implementation and optimization, and in the monitoring of the system s ongoing success or failure. Our recommendations apply to emergency departments using any type of EDIS: custom-developed systems, best-of-breed vendor systems, or enterprise systems. [Ann Emerg Med. 2013;62:399-407.] A podcast for this article is available at www.annemergmed.com. 0196-0644/$-see front matter Copyright 2013 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2013.05.019 INTRODUCTION The release of the 2 Institute of Medicine (IOM) reports, To Err is Human in 1999 and Crossing the Quality Chasm in 2001, focused local quality improvement and national policy efforts on reducing medical errors and improving patient safety. 1,2 One of the major interventions aimed at reducing medical errors was the development and use of electronic health records systems, also referred to as emergency department information systems (EDISs) when focused on the emergency department (ED). 3-6 The most significant legislation in this area was the Health Information Technology for Economic and Clinical Health Act of 2009, which was part of the American Recovery and Reinvestment Act and encouraged hospitals to implement such electronic records by 2011. It also promised financial penalties by 2015 Communication failure Poor data display Wrong-order-Wrong Patient Error Alert Fatigue EDISs are an important and unique component of this greater movement toward improving quality and outcomes with electronic health records. There is a wide variety of electronic systems with various functionality available for use by EDs throughout the country. Variation in EDIS functionality affects physician decisionmaking, clinician workflow, communication, and, ultimately, the overall quality of care and patient safety in a particularly challenging clinical environment (eg, high volume, time sensitive). However, the technology is constantly evolving and vendors are adapting to meet new demands by clinicians, health care administrators, and government, and as such, active engagement by front-line clinicians in improving these products is critical. Recently, studies have emerged in the literature examining 7-12
Recommendations 1 A local ED clinician champion should be appointed to maintain a performance improvement process for the EDIS and lead the EDIS performance improvement group. 2 A multidisciplinary EDIS performance improvement group should meet regularly and communicate regularly with ED and hospital leadership. 3 A review process should be in place to monitor ongoing patient safety issues with the EDIS. ED providers and other stakeholders should be encouraged to submit safety concerns for review. In addition, prospective risk assessments should be conducted regularly. 4 EDIS-related patient safety concerns identified by the review process should be addressed in a timely manner by ED providers, the EDIS vendors, and hospital administration. Each of these processes should be performed in full transparency, specifically with openness, communication, and accountability. 5 Lessons learned from performance improvement efforts should be measured and shared publicly, including with other EDs using the same EDIS. 6 EDIS vendors should learn from local patient safety improvements and ensure timely distribution of necessary changes to all installation sites. 7 Hold harmless or learned intermediary clauses should be removed from vendor software contracts. Annals of Emergency Medicine Volume 62, Issue 4, Pages 399-407, October 2013
Slide 7 of 23 Safety as a system property Safety is a characteristic of a sociotechnical system System-level failures occur almost always because of unforeseen combinations of component failures
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