EHR Safety - Identifying and Mitigating Health IT-related Risks (Webinar Slides)

WEBINAR WELCOME!

Raj RatwaniScientific director, National Center for Human Factors

in Healthcare, MedStar Institute for Innovation

Dr. Hardeep SinghChief of the health policy, quality

and informatics program, Michael E. DeBakey

VA Medical Center and Baylor College of Medicine

Joseph ConnModerator

Health information technology reporter Modern Healthcare

During today’s discussion, feel free to submit questions at any time by using the questions box.

A follow-up e-mail will be sent to all attendees with links to the presentation materials online.

Dr. Andy GettingerChief medical information officer and acting director,

Office of Clinical Quality and Safety, ONC

Panelists:

EHR SAFETY: Identifying and mitigating health IT-related risks

WEBINAR HOUSEKEEPING

NOW SPEAKING

Please use the questions box on your webinar dashboard to submit questions to our moderator

WEBINAREHR SAFETY: Identifying and mitigating health IT-related risks



NOW SPEAKING



Dr. Andy GettingerChief medical information officer

and acting director, Office of Clinical Quality and Safety,

ONC

ONC: EHR Usability

9/21/2015Office of the National Coordinator for

Health Information Technology0

• Focus on patient-centered

cognitive support for clinicians

• Short-term research that

addresses usability and

workflow

• Long-term research that can

remove key cognitive barriers

to HIT adoption and

meaningful use



http://inspiredehrs.org



• Nothing has been

approved at HHS or

Congress

• Seed money from HHS

• Public private

partnership

• Protected space for

work protected from

litigation

Safety Center is NOT

• A bricks and mortar

physical entity

• Federal entity collecting

data



ONC Current Activity in Usability



Thank You

Contact Information

[email protected]

www.healthit.gov

5

NOW SPEAKING



Dr. Hardeep SinghChief of the health policy, quality and

informatics program

Michael E. DeBakey VA Medical Center and Baylor College of Medicine

DEFINING AND MEASURING THE

INTERSECTION OF HEALTH IT

AND PATIENT SAFETY

HARDEEP SINGH, MD, MPHHOUSTON VETERANS AFFAIRS CENTER FOR INNOVATIONS IN

QUALITY, EFFECTIVENESS & SAFETY

MICHAEL E. DEBAKEY VA MEDICAL CENTER

BAYLOR COLLEGE OF MEDICINE

1

2

Safety Begins with Measurement

We cannot improve what we cannot

measure!

We cannot measure what we cannot

define!

3

8-dimensional Socio-Technical Model of Safe & Effective Health IT Use

4

Sittig Singh QSHC 2010

Health IT Safety Hierarchy – 3 Phases5

� Phase 1: Safe health IT:

� Events unique/specific to health IT

Sittig & Singh N Engl J Med. 2012 Nov 8;367(19):1854-60

6

Health IT Safety Hierarchy– 3 Phases7

� Phase 1: Safe health IT:

� Events unique/specific to health IT

� Phase 2: Using health IT safely:

� Unsafe or inappropriate use of technology

� Unsafe changes in the workflows that emerge from technology use


9

Health IT Safety Hierarchy – 3 Phases10

� Phase 1: Safe health IT :

� Events unique/specific to EHRs

� Phase 2: Using health IT safely:

� Unsafe or inappropriate use of technology

� Unsafe changes in the workflows that emerge from technology use

� Phase 3: Using health IT to improve safety

� Leveraging health IT to identify unsafe care processes and potential patient safety concerns before harm


Singh Sittig BMJ Qual Saf doi:10.1136/bmjqs-2015-004486

Which HIT-related Safety Concerns to Measure?

13

Type of HIT-related safety concern Examples

1. Instances in which HIT fails during use or is otherwise not working as designed.

Broken hardware or software “bugs”

2. Instances in which HIT is working as designed, but the design does not meet the user’s needs or expectations.

Usability issues

3. Instances in which HIT is well-designed and working correctly, but was not configured, implemented, or used in a way anticipated

or planned for by system designers and developers

Duplicate order alerts that fire on alternative PRN pain medications

Sittig Classen Singh J Am Med Inform Assoc. 2014 Oct 20

Which HIT-related Safety Concerns to Measure?

14

Type of HIT-related safety concern Examples

4. Instances in which HIT is working as designed, and was configured and used correctly, but interacts with external systems (e.g., via

hardware or software interfaces) so that

data is lost or incorrectly transmitted or

displayed.

Medication order for extended release morphine inadvertently changed to immediate release morphine by error in interface translation table

5. Instances in which specific safety features or functions were not implemented or not

available (i.e., HIT could have prevented a safety concern).

Hospitalized patient inadvertently receives 5 grams of acetaminophen in 24 hours because maximum daily dose alerting was not available

Sittig Classen Singh J Am Med Inform Assoc. 2014 Oct 20

Proactive Measurement

� ONC-sponsored “Safety Assurance Factors for EHR Resilience (SAFER) project”

� Proactive risk assessment and guidance

� “1st draft” of best practices and knowledge

� Self-assessment; not meant to be regulatory

� Focused on high-risk areas

� Nine guides—all freely available

Singh et al BMC Med Inf 2013

15

http://www.healthit.gov/safer

� Foundational Guides

� High Priority Practices

� Organizational Responsibilities

� Infrastructure Guides

� System Configuration

� System Interfaces

� Contingency Planning

� Clinical Process Guides

� Patient Identification

� Computerized Provider Order Entry with CDS

� Test Results Reporting and Follow-up

� Clinician Communication

SAFER: Safety Assurance Factors for EHR Resilience

Sittig, Singh, Ash. Am J Manag Care. 2014;20(5):418-423

16

http://www.healthit.gov/safer

SAFER Recommended Practices17

Take Home20

� Essential to have robust definitions & measurement approaches

� Certain risk areas are now well defined and amenable to local measurement for QI/safety purposes

� Measuring health IT-related safety needs to become an essential component of overall patient safety strategy

Thank you…21

Funding Agencies

� Department of Veterans Affairs

� Agency for Health Care Research & Quality

� National Institute of Health

� Office of National Coordinator (SAFER Guides)

� Multidisciplinary team at Houston-based VA Health Services Research Center of Innovation

Contact Information…

Hardeep Singh, MD, MPH

[email protected]

@HardeepSinghMD

NOW SPEAKING



Raj RatwaniScientific director

National Center for Human Factors in Healthcare,

MedStar Institute for Innovation

Health IT Usability, Clinician

Workflow, and Safety Hazard

Identification

Raj Ratwani, PhD

Scientific Director

National Center for Human Factors in Healthcare,

MedStar Health

Assistant Professor of Emergency Medicine,

Georgetown University

1: User Interface Design

Displays and Controls

Screen Design

Clicks & Drags

Colors & Navigation

The Two Bins of Usability

2: Cognitive Task Support

“Workflow Design”

Smart Data Visualization

Support Cognitive Work

Functionality

Photo credit to Bob Wears, MD, PhD

EHR Usability

• Many vendors are not employing rigorous User-

centered design processes

• Safety enhanced design reports demonstrate:

– Many vendors are not adhering to

requirements

– Testing standards are violated

• What is the frontline impact?

Ratwani, R.M., Benda, N., Hettinger, A.Z., & Fairbanks, R.J. (2015) Electronic Health Record Vendor Adherence to Usability

Certification Requirements and Testing Standards. Journal of the American Medical Association (JAMA) 314(10):1070-1071.

Ratwani, R.M., Fairbanks, R.J., Hettinger, A.Z. & Benda, N. (2015). Electronic Health Record Usability: Analysis of the User Centered

Design Processes of Eleven Electronic Health Record Vendors. Journal of the American Medical Informatics Association.

Frontline Impact

• How does use of a new EHR with CPOE impact physician performance in the ED?– Three study periods: pre, go-live, post

– 2 hour observation periods

– 14 EM physicians during each phase

• Observers record minute by minute allocation to different tasks– Computer, verbal communication, patient

time, paper

Benda, N., Meadors, MA, Hettinger, A.Z, and Ratwani, R.M. (in

press). Emergency Physician Task Switching Increases with the

Introduction of a Commercial EHR. Annals of Emergency Medicine

Task Allocation Time




Tasks Per Minute




Significant Increase in Task

Switching

• The cognitive cost of the EHR is increased

task switching:

– Increased stress and frustration

– Increase likelihood of error

• Users are forced to adapt their work

practices to the EHR




Strategies for Identifying Safety

Hazards

• Observation and analysis in highest risk

clinical environments

– Task tracking, visualization and analysis

• Leveraging event reporting systems and

help desk data

– Visualization and natural language processing

Fong, A. & Ratwani, R.M. (2015). An Evaluation of Patient

Safety Event Report Categories Using Unsupervised Topic

Modeling. Methods of Information in Medicine. 54 (3).

Task Tracker

Workflow Visual Analytics Tool

Data Analytics

• Identify health IT related safety events

from adverse event data

– Visualization and natural language processing

techniques

• Examining “help desk” data to identify

patterns and trends

Thank you

Raj Ratwani, PhD

[email protected]

@RajRatwani

WEBINAR

TODAY’S PANELISTS


During today’s discussion, feel free to submit questions at any time by using the questions box

Raj RatwaniScientific director, National Center for Human Factors

in Healthcare, MedStar Institute for Innovation

Dr. Hardeep SinghChief of the health policy,

quality and informatics program, Michael E. DeBakey

VA Medical Center and Baylor College of Medicine



Dr. Andy GettingerChief medical information officer and acting director,

Office of Clinical Quality and Safety, ONC

Expect a follow-up email within two weeks with links to presentation materials and information about how to offer feedback.

For more information about upcoming webinars, please visit ModernHealthcare.com/webinars

WEBINAR THANK YOU FOR ATTENDING

Thanks also to our panelists:


Raj RatwaniScientific director, National Center for Human Factors in Healthcare, MedStar Institute for Innovation

Dr. Hardeep SinghChief of the health policy, quality and informatics program, Michael E. DeBakey VA Medical Center and Baylor College of Medicine

Joseph ConnModeratorHealth information technology reporter Modern Healthcare

Dr. Andy GettingerChief medical information officer, acting director, Office of Clinical Quality and Safety, ONC