First Do No Harm: Ensuring the Safe and Effective Use of Health IT

2009 Healthcare Information and Management Systems Society

First Do No Harm: Ensuring the Safe and

Effective Use of Health IT

AHRQ 2009 Annual ConferenceAHRQ 2009 Annual Conference

Bethesda, MD - Monday September 14, Bethesda, MD - Monday September 14, 2009, 3-4:30pET2009, 3-4:30pET

Carla Smith, CNM, FHIMSSCarla Smith, CNM, FHIMSS

Executive Vice PresidentExecutive Vice President

2

Overview• HIMSS Background

• Review Questions

• Highlight Relevant HIMSS Activities– Davies Award– Usability White Paper

• Questions

HIMSS Strategic DirectionVision

Advancing the best use of information and mgt systems for the betterment of health care.

Mission

Lead healthcare transformation through the effective use of health information technology.

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• Role of Health IT in preventing errors

• Role of Health IT in introducing errors

• How to ensure the safe and effective use of Health IT

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Role of Health IT in preventing errors• Provide availability of information to providers • Improve collaboration between providers• Reduce human error at the point of care through

Clinical Decision Support (alerts and rules) based on standard clinical norms and guidelines

• Provide workflow automation and improvement• Enable Computerized Provider Order Entry

(CPOE) and reduction of adverse drug events• Enable the 5 Rights of Medication Administration

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Clinical Decision Support (CDS)• Detect potential safety and quality problems and help prevent them

• Detect inappropriate utilization of services, medications, and supplies

• Foster the greater use of evidence-based medicine principles and guidelines

• Organize, optimize and help operationalize the details of a plan of care

• Help gather and present data needed to execute this plan

• Ensure that the best clinical knowledge and recommendations are utilized to improve health management decisions by clinicians and patients

Osheroff JA, Pifer EA, Teich JM, et al. Improving Outcomes with Clinical Decision Support: An Implementers’ Guide. Chicago: HIMSS; 2005.

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• Role of Health IT in preventing errors

• Role of Health IT in introducing errors

• How to ensure the safe and effective use of Health IT

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Unintended or Unwanted Consequences

• Iatrogenesis: – Not new in the literature

• Unintended harm caused by clinicians

• E-Iatrogenesis - electronic iatrogenesis– Unintended consequences through the use of

computerized provider order entry (CPOE)

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• System demands– Need for continuous equipment upgrades

• Extended workflow– Extra time to enter orders

• Power shifts– Decisions made by ancillary clinical staff– Improved collaboration and sharing among sites*

• New error types– Entering orders on the wrong patient – Incongruence of process change with existing mental model*– Hand-offs*

• Dependence on the system– Downtime– Defaults leading to increased errors*

• More work or new work– Non-standard cases, call for more steps in ordering– Additional post-live education and support requirements*

Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry JAMIA, April 2007: 12:315-423

* Examples from Allina Hospitals & Clinics, 2007 Davies Organizational Award

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• Role of health IT in preventing errors

• Role of health IT in introducing errors

• How to ensure the safe and effective use of health IT

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How to ensure the safe and effective use of Health IT

• Involve care providers • Engage facility leadership• Utilize the 13 Joint Commission Suggested Actions• Follow EMR Usability Principles• Relentless Discovery of New Patient Safety Solutions to

Emerging Problems

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Joint Commission Sentinel Event Alert No. 42

1. Examine workflow processes and procedures 2. Actively involve clinicians and staff 3. Assess your organization’s technology needs beforehand 4. During the introduction of new technology, continuously monitor

for problems 5. Establish a training program 6. Develop and communicate policies delineating staff authorized

and responsible 7. Prior to taking a technology live, ensure that all standardized

order sets and guidelines are developed, tested on paper, and approved by the Pharmacy and Therapeutics Committee (or institutional equivalent).

13

Joint Commission Sentinel Event Alert No. 428. Develop a graduated system of safety alerts in the new technology

that helps clinicians determine urgency and relevancy. 9. Develop a system that mitigates potential harmful CPOE drug orders

by requiring departmental or pharmacy review and sign off on orders that are created outside the usual parameters.

10. To improve safety, provide an environment that protects staff involved in data entry from undue distractions when using the technology.

11. After implementation, continually reassess and enhance safety effectiveness and error-detection capability.

12. After implementation, continually monitor and report errors and near misses or close calls caused by technology through manual or automated surveillance technique.

13. Re-evaluate the applicability of security and confidentiality protocols as more medical devices interface with the IT network.

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm



Davies Award

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Davies Awards of ExcellenceEncourages and recognizes excellence in the implementation of HERsystems

– Implementation– Strategy– Planning– Project Management– Governance– Value and ROI

Objectives – Promote the vision of EHR Systems through concrete examples– Understand and share documented value of EHR Systems– Provide visibility and recognition for high-impact EHR Systems– Share successful EHR imlementation strategies

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Office of the CMIO- Ongoing Feedback • CPOE intranet

– Clinical staff send questions and/or feedback– Feedback reviewed by:

• Team of clinical coordinators (from the Office of the CMIO), Information Systems staff and clinical educators

• Identify, resolve technical, process or training issues

– Intranet provides complete transparency• Site displays all the issues the user reported since CPOE was

implemented

• “CMIO Newsletter”– Articles on CPOE, other EHR implementation status, Service and

Section meetingsEastern Maine Medical Center – ‘08 Davies Organizational Award

During the introduction of new technology,

continuously monitor for problems

Alert Fatigue• Overriding alerts without reading the alerts

• Documented unintended consequence of CPOE

• To minimize this risk, EMMC opted to

• Start slowly with the minimum number of alerts firing to the providers

• …But all firing to the pharmacists

• Reduction in drug-drug alert firing to providers

• Significantly decreased the “noise” and negative impact on provider ordering while maintaining patient safety

• 17,498 alerts/month to 2,401 alerts/month

17Eastern Maine Medical Center, Davies ‘08 Organizational Award of Excellence

Graduated system of safety alerts in the new technology that helps

clinicians determine urgency and relevancy


EMR USABILITY

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EMR Usability• “Defining and Testing EMR Usability”

– Effectiveness– Efficiency– Satisfaction

http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf



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EMR Usability Principles–Simplicity–Naturalness–Consistency–Minimizing cognitive load–Efficient interactions–Forgiveness–Feedback–Effective use of language–Effective information presentation–Preservation of context

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Example Simplicity

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Carla Smith, CNM, FHIMSS

Executive Vice President

HIMSS

(734) 477-0860 office

(734) 604-6275 cell

[email protected]

For additional information:


BACKGROUND

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CDS: (How) Does it Work?Two Examples

Medications– Suggesting brand to generic substitutions for medications,

alternative, more cost-effective therapies, or more formulary compliant drug options

– Selecting complex dosages (renal failure or geriatrics) and supporting drug-level monitoring are additional advantages of CDS

Radiological tests and procedures – Support at the point of ordering can guide physicians toward

the most appropriate and cost effective, radiological tests

Osheroff JA, editor. Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step

Guide. Chicago: HIMSS; 2009. (www.himss.org/cdsguide)

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Davies: Role of Health IT in Preventing Errors

CDS• Alerts and reminders • Clinical guidelines• Order sets• Patient data reports,

dashboards• Documentation templates • Diagnostic support• Reference information

• Decision support feature identified 164,250 alerts, resulting in 82,125 prescription changes

• Problem medication orders dropped 58%, medication discrepancies by 55%

• Addressed “high alert medications,” confusing look-a-like and sound-alikedrug names, patients with similar names

Maimonides Medical Center, 2002 HIMSS Davies Organizational Award

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o Created a process to reduce drug utilization

o Ability to generate a system list of specific IV medications, which can be changed to PO medications without contacting a provider

• PO medications are a less costly route of therapy

• Chance of infection from IV use is decreased

• Average length of stay is reduced

• Pharmacy and Nursing time to prepare and administer medication is reduced

Allina Hospitals & Clinics, 2007 HIMSS Davies Organizational Award


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• New procedures regarding a medication could be introduced

in just hours– Problems with Dilaudid, e.g,

brought about different recommended doses in patients

• Changed 32 order sets and 22 preference lists in 3 hours

• Omitted administration of medications decreased 22%

from a total of 18 to 14 a month

Evanston Northwestern Healthcare, 2004 HIMSS Davies Organizational Award


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“Pre-EHR”…

• Offices relied on the patients to return for repeat INR blood tests

– 7,267 patients in the practice currently prescribed warfarin (an unknowable # prior to EMR)

“EHR”…

• Customized encounter form for warfarin management– Weekly reports

• Identifies patients overdue

– Patients overdue as much as 6 to 12 months

– Nurses contact patients, facilitate compliance with anticoagulation monitoring.

Cardiology Consultants of Philadelphia, 2008 HIMSS Davies Ambulatory Award


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Device Recall:• Medtronic's Fidelis defibrillator lead

– Queried EHR database• Able to identify all patients

implanted with this lead, 10 minutes after recall notification

• Identified 100+patients beyond those identified in the records of the device manufacturer

– Mail-merge form letters created• Notified all patients within

hours (not weeks as pre-EHR)• Device manufacture modified

their local processes for collecting implanted lead data

Cardiology Consultant of Philadelphia, 2008 HIMSS Davies Ambulatory Award


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• Improved allergy documentation 88%100%

• Improved pain assessment documentation95%

• Improved medication list documentation 67%100%

Maimonides Medical Center, 2002 HIMSS Davies Organizational Award


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Role of Health IT in Preventing Errors



Regional PACS (Picture Archiving and Communication System):– Enables access to images and

concurrent review by multiple providers in separate locations across the region, thereby, improving the clinical effectiveness and patient outcomes

– Radiologists and other specialists can access studies for timely online comparison from the same PACS system allowing broad and rapid access to images

Eastern Maine Medical Center, 2008 HIMSS Davies Organizational Award

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Role of Health IT in Preventing Errors



Access to drug references:• Desktop access via the

intranet is possible to Micromedex, OVID, ENH* Formulary, ENH Drug Use Guidelines, ENH Policy & Procedures, IV Administration Guidelines, and several other secondary and tertiary medical references.

Evanston Northwestern Healthcare (*ENH), 2004 HIMSS Davies Ambulatory Award

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• Role of health IT in preventing errors

• Role of health IT in introducing errors

• How to ensure the safe and effective use of health IT

34

Unintended or Unwanted Consequences

• Iatrogenesis: – Not new in the literature

• Unintended harm caused by clinicians

• eIatrogenesis - electronic iatrogenesis– Unintended consequences through the use of

computerized provider order entry (CPOE)

35

Cause Number %

Barcode, medication mislabeled

20 5

Information management system

1,176 2

Computer screen display unclear/confusing

137 1.5

Dispensing device involved

3,181 1.3

Barcode, failure to scan 114 <1

Computer entry (general, other than CPOE)

24,715 <1

CPOE 10,752 <1

Barcode, override warning 41 0

176,409 medication error records for ‘06, 1.25% resulted in harm

Joint Commission Sentinel Event Alert No. 42

Dec ‘08 http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

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1. More or new work

2. Extended workflow

3. System demands

4. Emotions

5. New kinds of errors

6. Power shifts

7. Dependence on the system

1. Non-standard cases call for more steps in ordering

2. Extra time to enter orders

3. Need for continuous equipment upgrades

4. Both positive & negative

5. Entering orders on the wrong patient

6. Decisions made by ancillary clinical staff

7. Downtime creates a major issue

The Extent and Importance of Unintended Consequences Related to

Computerized Provider Order Entry, JAMIA, April 2007: 12:315-423

37

Lessons Learned: Unanticipated

Consequences

• Hand Offs – New Issues• Novice Errors – Medications• Nurse/Physician

Communication• Defaults leading to

increased errors• Improved collaboration and

sharing among sites• Individual growth

• Rapid Dependence on Automation

• Additional post-live education and support requirements

• Incongruence of process change with existingmental model

• Emotions • Order Sets

Allina Hospitals & Clinics,’07 HIMSS Davies Organizational Award

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Human Factors – Lessons Learned:

Unanticipated Consequences

• Scanning troubles-low contrast. Some older prefilled fluid and medication bags had bar codes that identified their contents (great!) but these codes were printed in white ink on clear bags, rendering

scanning impossible.

• Mitigating StrategyMost fluid and medication suppliers have moved to higher-contrast printing, typically black or blue on clear bags.

•Other ExamplesIntegrating Medical Devices with Clinical Documentation

Systems: A Quick-Start Guide

www.himss.org/ASP/topics_FocusDynamic.asp?faid=295

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Joint Commission Sentinel Event Alert No. 42http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm

• Safety and effectiveness of technology in health care ultimately depend on its human users, ideally working in close concert with properly designed and installed electronic systems.

• Any form of technology may adversely affect the quality and safety of care if it is designed or implemented improperly or is misinterpreted.

• Not only must the technology or device be designed to be safe, it must also be operated safely within a safe workflow processes.



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1. Examine workflow processes and procedures 2. Actively involve clinicians and staff 3. Assess your organization’s technology needs beforehand 4. During the introduction of new technology, continuously monitor for

problems 5. Establish a training program 6. Develop and communicate policies delineating staff authorized and

responsible 7. Prior to taking a technology live, ensure that all standardized order

sets and guidelines are developed, tested on paper, and approved by the Pharmacy and Therapeutics Committee (or institutional equivalent).



41

Office of the CMIO- Ongoing Feedback • CPOE intranet

– Clinical staff send questions and/or feedback– Feedback reviewed by:

• Team of clinical coordinators (from the Office of the CMIO), Information Systems staff and clinical educators

• Identify, resolve technical, process or training issues

– Intranet provides complete transparency• Site displays all the issues the user reported since CPOE was

implemented

• “CMIO Newsletter”– Articles on CPOE, other EHR implementation status, Service and

Section meetingsEastern Maine Medical Center – ‘08 Davies Organizational Award

During the introduction of new technology,

continuously monitor for problems

42


8. Develop a graduated system of safety alerts in the new technology that helps clinicians determine urgency and relevancy.

9. Develop a system that mitigates potential harmful CPOE drug orders by requiring departmental or pharmacy review and sign off on orders that are created outside the usual parameters.

10. To improve safety, provide an environment that protects staff involved in data entry from undue distractions when using the technology.

11. After implementation, continually reassess and enhance safety effectiveness and error-detection capability.

12. After implementation, continually monitor and report errors and near misses or close calls caused by technology through manual or automated surveillance technique.

13. Re-evaluate the applicability of security and confidentiality protocols as more medical devices interface with the IT network.



Alert Fatigue• Overriding alerts without reading the alerts

• Documented unintended consequence of CPOE

• To minimize this risk, EMMC opted to

• Start slowly with the minimum number of alerts firing to the providers

• …But all firing to the pharmacists

• Reduction in drug-drug alert firing to providers

• Significantly decreased the “noise” and negative impact on provider ordering while maintaining patient safety

• 17,498 alerts/month to 2,401 alerts/month

43Eastern Maine Medical Center, Davies ‘08 Organizational Award of Excellence

Graduated system of safety alerts in the new technology that helps

clinicians determine urgency and relevancy

44

• Collect and Report Care and Revenue Cycle Information in a Standardized Meaningful Way– Core and Community Measures– Reports provided for individual practitioner

achievement vs. the goal– Sites celebrate their achievement of optimal

care goalsAllina Hospitals & Clinics, 2007 HIMSS Davies Organizational Award

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• Hard Wire Best Practices Across the System Quickly– Order Sets– Best Practice Alerts– Rules– Plans of Care


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• Impact Care Proactively and at the Time of Patient Contact– Order Sets– Rules and Alerts– Medication Recalls– Real Time Reporting– Atherosclerosis Pilot– Diabetes Patients Entering Data into Chart


First Do No Harm: Ensuring the Safe and Effective Use of Health IT

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