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

1
First Do No Harm Ensuring the Safe and
Effective Use of Health IT

• AHRQ 2009 Annual Conference
• Bethesda, MD - Monday September 14, 2009,
  3-430pET
• Carla Smith, CNM, FHIMSS
• Executive Vice President

2
Overview

• HIMSS Background
• Review Questions
• Highlight Relevant HIMSS Activities
• Davies Award
• Usability White Paper
• Questions

3
HIMSS Strategic Direction

• Vision
• 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.

4

• 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

5
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

6
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.
7

• 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

8
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)

9
Extent and Importance of Unintended Consequences
Related to Computerized Provider Order Entry
JAMIA, April 2007 12315-423

• 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

Examples from Allina Hospitals Clinics, 2007
Davies Organizational Award
10

• 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

11
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

12
Joint Commission Sentinel Event Alert No. 42

• Examine workflow processes and procedures
• Actively involve clinicians and staff
• Assess your organizations technology needs
  beforehand
• During the introduction of new technology,
  continuously monitor for problems
• Establish a training program
• Develop and communicate policies delineating
  staff authorized and responsible
• 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. 42

• Develop a graduated system of safety alerts in
  the new technology that helps clinicians
  determine urgency and relevancy.
• 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.
• To improve safety, provide an environment that
  protects staff involved in data entry from undue
  distractions when using the technology.
• After implementation, continually reassess and
  enhance safety effectiveness and error-detection
  capability.
• After implementation, continually monitor and
  report errors and near misses or close calls
  caused by technology through manual or automated
  surveillance technique.
• Re-evaluate the applicability of security and
  confidentiality protocols as more medical devices
  interface with the IT network.
• http//www.jointcommission.org/Sen
  tinelEvents/SentinelEventAlert/sea_42.htm

14
Davies Award
15
Davies Awards of Excellence

• Encourages and recognizes excellence in the
  implementation of HER
• systems
• 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

16
During the introduction of new technology,
continuously monitor for problems

• 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 meetings
• Eastern Maine Medical Center 08 Davies
  Organizational Award

17
Alert Fatigue
Graduated system of safety alerts in the new
technology that helps clinicians determine
urgency and relevancy

• 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

Eastern Maine Medical Center, Davies 08
Organizational Award of Excellence
18
EMR USABILITY
19
EMR Usability

• Defining and Testing EMR Usability
• Effectiveness
• Efficiency
• Satisfaction

http//www.himss.org/content/files/HIMSS_Defining
andTestingEMRUsability.pdf
20
EMR Usability Principles

• Simplicity
• Naturalness
• Consistency
• Minimizing cognitive load
• Efficient interactions
• Forgiveness
• Feedback
• Effective use of language
• Effective information presentation
• Preservation of context

21
Example Simplicity
22
For additional information

• Carla Smith, CNM, FHIMSS
• Executive Vice President
• HIMSS
• [phone] office
• [phone] cell
• csmith_at_himss.org

23
BACKGROUND
24
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)
25
Davies Role of Health IT in Preventing Errors

• 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-alike
• drug names, patients with similar names

• CDS
• Alerts and reminders
• Clinical guidelines
• Order sets
• Patient data reports, dashboards
• Documentation templates
• Diagnostic support
• Reference information

Maimonides Medical Center, 2002 HIMSS Davies
Organizational Award
26
Davies Role of Health IT in Preventing Errors

• Created a process to reduce drug utilization
• 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

• CDS
• Alerts and reminders
• Clinical guidelines
• Order sets
• Patient data reports, dashboards
• Documentation templates
• Diagnostic support
• Reference information

Allina Hospitals Clinics, 2007 HIMSS Davies
Organizational Award
27
Davies Role of Health IT in Preventing Errors

• 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

• CDS
• Alerts and reminders
• Clinical guidelines
• Order sets
• Patient data reports, dashboards
• Documentation templates
• Diagnostic support
• Reference information

Evanston Northwestern Healthcare, 2004 HIMSS
Davies Organizational Award
28
Davies Role of Health IT in Preventing Errors

• 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.

• CDS
• Alerts and reminders
• Clinical guidelines
• Order sets
• Patient data reports, dashboards
• Documentation templates
• Diagnostic support
• Reference information

Cardiology Consultants of Philadelphia, 2008
HIMSS Davies Ambulatory Award
29
Davies Role of Health IT in Preventing Errors

• 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 100patients 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

• CDS
• Alerts and reminders
• Clinical guidelines
• Order sets
• Patient data reports, dashboards
• Documentation templates
• Diagnostic support
• Reference information

Cardiology Consultant of Philadelphia, 2008
HIMSS Davies Ambulatory Award
30
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

• Improved allergy documentation 88?100
• Improved pain assessment documentation?95
• Improved medication list documentation 67?100

Maimonides Medical Center, 2002 HIMSS Davies
Organizational Award
31
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

• CDS
• Alerts and reminders
• Clinical guidelines
• Order sets
• Patient data reports, dashboards
• Documentation templates
• Diagnostic support
• Reference information

Eastern Maine Medical Center, 2008 HIMSS Davies
Organizational Award
32
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.

• CDS
• Alerts and reminders
• Clinical guidelines
• Order sets
• Patient data reports, dashboards
• Documentation templates
• Diagnostic support
• Reference information

Evanston Northwestern Healthcare (ENH), 2004
HIMSS Davies Ambulatory Award
33

• 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
Joint Commission Sentinel Event Alert No. 42Dec
08 http//www.jointcommission.org/SentinelEvents/
SentinelEventAlert/sea_42.htm
176,409 medication error records for 06, 1.25
resulted in harm
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 lt1
Computer entry (general, other than CPOE) 24,715 lt1
CPOE 10,752 lt1
Barcode, override warning 41 0
36
The Extent and Importance of Unintended
Consequences Related to Computerized Provider
Order Entry, JAMIA, April 2007 12315-423

• Non-standard cases call for more steps in
  ordering
• Extra time to enter orders
• Need for continuous equipment upgrades
• Both positive negative
• Entering orders on the wrong patient
• Decisions made by ancillary clinical staff
• Downtime creates a major issue

• More or new work
• Extended workflow
• System demands
• Emotions
• New kinds of errors
• Power shifts
• Dependence on the system

37
Lessons Learned Unanticipated Consequences
Allina Hospitals Clinics,07 HIMSS Davies
Organizational Award

• Rapid Dependence on Automation
• Additional post-live education and support
  requirements
• Incongruence of process change with
  existingmental model
• Emotions
• Order Sets

• Hand Offs New Issues
• Novice Errors Medications
• Nurse/Physician Communication
• Defaults leading to increased errors
• Improved collaboration and sharing among sites
• Individual growth

38
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 Strategy
• Most fluid and medication suppliers have moved to
  higher-contrast printing, typically black or blue
  on clear bags.
• Other Examples
• Integrating Medical Devices with Clinical
  Documentation
• Systems A Quick-Start Guide

www.himss.org/ASP/topics_FocusDynamic.asp?faid295
39
Joint Commission Sentinel Event Alert No.
42http//www.jointcommission.org/SentinelEvents/S
entinelEventAlert/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.

40
Joint Commission Sentinel Event Alert No.
42http//www.jointcommission.org/SentinelEvents/S
entinelEventAlert/sea_42.htm

• Examine workflow processes and procedures
• Actively involve clinicians and staff
• Assess your organizations technology needs
  beforehand
• During the introduction of new technology,
  continuously monitor for problems
• Establish a training program
• Develop and communicate policies delineating
  staff authorized and responsible
• 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
During the introduction of new technology,
continuously monitor for problems

• 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 meetings
• Eastern Maine Medical Center 08 Davies
  Organizational Award

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

• Develop a graduated system of safety alerts in
  the new technology that helps clinicians
  determine urgency and relevancy.
• 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.
• To improve safety, provide an environment that
  protects staff involved in data entry from undue
  distractions when using the technology.
• After implementation, continually reassess and
  enhance safety effectiveness and error-detection
  capability.
• After implementation, continually monitor and
  report errors and near misses or close calls
  caused by technology through manual or automated
  surveillance technique.
• Re-evaluate the applicability of security and
  confidentiality protocols as more medical devices
  interface with the IT network.

43
Alert Fatigue
Graduated system of safety alerts in the new
technology that helps clinicians determine
urgency and relevancy

• 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

Eastern Maine Medical Center, Davies 08
Organizational Award of Excellence
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
  goals

Allina Hospitals Clinics, 2007 HIMSS Davies
Organizational Award
45

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

Allina Hospitals Clinics, 2007 HIMSS Davies
Organizational Award
46

• 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

Allina Hospitals Clinics, 2007 HIMSS Davies
Organizational Award