The Health IT Patient Safety Journey in the United States Patricia P. Sengstack DNP, RN-BC, CPHIMS Chief Nursing Informatics Officer Bon Secours Health System Marriottsville, Maryland, USA 1
To Err is Human Institute of Medicine (IOM) 1999 now the National Academy of Medicine Landmark publication that brought safety to the forefront of healthcare for the USA At least 44,000 and perhaps as many as 98,000 people die in hospitals each year as the result of medical errors that could have been prevented 2
JAMA, July 5, 2000 Vol 284, No. 193 3
To Err Is Human - Recommendations Establishing a national focus to create leadership, research, tools and protocols to enhance the knowledge base about safety; Identifying and learning from errors through immediate and strong mandatory reporting efforts, as well as the encouragement of voluntary efforts, both with the aim of making sure the system continues to be made safer for patients; Raising standards and expectations for improvements in safety through the actions of oversight organizations, group purchasers, and professional groups; and Creating safety systems inside health care organizations through the implementation of safe practices at the delivery level. This level is the ultimate target of all the recommendations. 4
To Err is Human Technology Focus (1999) Despite the computer-based patient record being almost here for 45 years it has still not arrived. It s advantages are clear: computer-based patient records and other systems give physicians and other authorized personnel the ability to access patient data without delay at any time in any place; ensure that services are obtained and track outcomes of treatment; and aggregate data from large numbers of patients, both to measure outcomes of treatment; and to promptly recognize complications of new drugs, devices,and treatments. 5
Literature on EHR Safety (2003 2007) Supporting Error Reduction Effects of computerized physician order entry and clinical decision support systems on medication safety; A systematic review by Kaushal, Shojania & Bates (2003) Error reduction in pediatric chemotherapy computerized order entry and failure modes and effects analysis by Kim, et. al. (2006) Medication errors: a prospective cohort study of hand-written and computerized physician order entry in the intensive care unit by Shulman, Singer, Goldstone & Bellingan (2005) Randomized trial to improve prescribing safety during pregnancy by Raebel et. al. (2007) Supporting Error Causation Role of computerized physician order entry systems in facilitating medication errors by Koppel, et. al. (2005) Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system by Han, et. al. (2005) Types of unintended consequences related to computerized provider order entry by Campbell, Sittig, Ash, Guappone and Dykstra (2006) Medication errors related to computerized order entry for children by Walsh (2006) 6
American Recovery & Reinvestment Act - 2009 Component of the ARRA - The Health Information Technology for Economic and Clinical Health (HITECH) Act Feb. 17, 2009 Promote the adoption and meaningful use of health information technology Contains specific incentives designed to accelerate the adoption of electronic health record (EHR) systems among providers Incentives align with implementation and Meaningful Use of EHRs 7
The White House: President Barack Obama. More than Half of Doctors Now Use Electronic Health Records Thanks to Administration Policies https://www.whitehouse.gov/blog/2013/05/24/more-half-doctors-now-useelectronic-health-records-thanks-administration-policies 8
Health IT and Patient Safety: Building Safer Systems for Better Care Published in November 2011 by the Institute of Medicine 9
IOM Report Recommendations The Secretary of Health and Human Services (HHS) should: Publish an action and surveillance plan within 12 months that includes a schedule for working with the private sector to assess the impact of health IT on patient safety and minimizing the risk of its implementation and use. Ensure insofar as possible that health IT vendors support the free exchange of information about health IT experiences and issues and not prohibit sharing of such information, including details (e.g., screenshots) relating to patient safety. Fund a new Health IT Safety Council to evaluate criteria for assessing and monitoring the safe use of health IT and the use of health IT to enhance safety. This council should operate within an existing voluntary consensus standards organization. 10
IOM Report Recommendations The Secretary of HHS should; Specify the quality and risk management process requirements that health IT vendors must adopt, with a particular focus on human factors, safety culture, and usability. Establish a mechanism for both vendors and users to report health IT related deaths, serious injuries, or unsafe conditions. Recommend that Congress establish an independent federal entity for investigating patient safety deaths, serious injuries, or potentially unsafe conditions associated with health IT. HHS, in collaboration with other research groups, should support crossdisciplinary research toward the use of health IT as part of a learning health care system. Specific areas of research include User-centered design and human factors applied to health IT, Safe implementation and use of health IT by all users, Sociotechnical systems associated with health IT, and Impact of policy decisions on health IT use in clinical practice. 11
Health IT Patient Safety Action & Surveillance Plan Health IT Patient Safety Action & Surveillance Plan July 2013 Addresses IOM recommendations with goals and two main objectives Use health IT to make care safer Continuously improve the safety of health IT 12
Health IT Patient Safety Action & Surveillance Plan Learn Increase the quantity and quality of data and knowledge about health IT safety. Improve Target resources and corrective actions to improve health IT safety Lead Promote a culture of safety related to health IT http://www.healthit.gov/policy-researchersimplementers/health-it-and-patient-safety How to handle safety in electronic records continues to evolve. Still learning. 13
The Journey Continues July 2015 14
patricia_sengstack@bshsi.org Patricia P. Sengstack DNP, RN-BC, CPHIMS Chief Nursing Informatics Officer Bon Secours Health System, Inc. Center for Clinical Excellence and Innovation 1505 Marriottsville Road Marriottsville, MD 21104 15