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First Do No Harm: Ensuring the Safe and Effective Use of Health IT . AHRQ 2009 Annual Conference Bethesda, MD - Monday September 14, 2009, 3-4:30pET Carla Smith, CNM, FHIMSS Executive Vice President. Overview. HIMSS Background Review Questions Highlight Relevant HIMSS Activities

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First do no harm ensuring the safe and effective use of health it

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

AHRQ 2009 Annual Conference

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

Carla Smith, CNM, FHIMSS

Executive Vice President


Overview

Overview

  • HIMSS Background

  • Review Questions

  • Highlight Relevant HIMSS Activities

    • Davies Award

    • Usability White Paper

  • Questions


Himss strategic direction

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.


First do no harm ensuring the safe and effective use of health it

  • 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


Role of health it in preventing errors

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


Clinical decision support cds

Detectpotential safety and quality problems and help prevent them

Detect inappropriate utilization of services, medications, and supplies

Fosterthe 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

Clinical Decision Support (CDS)

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


First do no harm ensuring the safe and effective use of health it

  • 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


Unintended or unwanted consequences

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)


First do no harm ensuring the safe and effective use of health it

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

  • 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


First do no harm ensuring the safe and effective use of health it

  • 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


How to ensure the safe and effective use of health it

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


Joint commission sentinel event alert no 42

Joint Commission Sentinel Event Alert No. 42

  • Examine workflow processes and procedures

  • Actively involve clinicians and staff

  • Assess your organization’s 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).


Joint commission sentinel event alert no 421

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/SentinelEvents/SentinelEventAlert/sea_42.htm


Davies award

Davies Award


Davies awards of excellence

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


First do no harm ensuring the safe and effective use of health it

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


Alert fatigue

Graduated system of safety alerts in the new technology that helps clinicians determine

urgency and relevancy

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

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


Emr usability

EMR USABILITY


Emr usability1

EMR Usability

  • “Defining and Testing EMR Usability”

    • Effectiveness

    • Efficiency

    • Satisfaction

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


Emr usability principles

EMR Usability Principles

Simplicity

Naturalness

Consistency

Minimizing cognitive load

Efficient interactions

Forgiveness

Feedback

Effective use of language

Effective information presentation

Preservation of context


Example simplicity

Example Simplicity


For additional information

For additional information:

Carla Smith, CNM, FHIMSS

Executive Vice President

HIMSS

(734) 477-0860 office

(734) 604-6275 cell

[email protected]


Background

BACKGROUND


Cds how does it work

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)


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-alike

drug names, patients with similar names

Davies: Role of Health IT in Preventing Errors

Maimonides Medical Center, 2002 HIMSS Davies Organizational Award


Davies role of health it in preventing errors1

CDS

Alerts and reminders

Clinical guidelines

Order sets

Patient data reports, dashboards

Documentation templates

Diagnostic support

Reference information

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

Davies: Role of Health IT in Preventing Errors

Allina Hospitals & Clinics, 2007 HIMSS Davies Organizational Award


First do no harm ensuring the safe and effective use of health it

CDS

Alerts and reminders

Clinical guidelines

Order sets

Patient data reports, dashboards

Documentation templates

Diagnostic support

Reference information

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

Davies: Role of Health IT in Preventing Errors

Evanston Northwestern Healthcare, 2004 HIMSS Davies Organizational Award


Davies role of health it in preventing errors2

CDS

Alerts and reminders

Clinical guidelines

Order sets

Patient data reports, dashboards

Documentation templates

Diagnostic support

Reference information

“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.

Davies: Role of Health IT in Preventing Errors

Cardiology Consultants of Philadelphia, 2008 HIMSS Davies Ambulatory Award


Davies role of health it in preventing errors3

CDS

Alerts and reminders

Clinical guidelines

Order sets

Patient data reports, dashboards

Documentation templates

Diagnostic support

Reference information

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

Davies: Role of Health IT in Preventing Errors

Cardiology Consultant of Philadelphia, 2008 HIMSS Davies Ambulatory Award


Davies role of health it in preventing errors4

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%

Davies: Role of Health IT in Preventing Errors

Maimonides Medical Center, 2002 HIMSS Davies Organizational Award


Role of health it in preventing errors1

CDS

Alerts and reminders

Clinical guidelines

Order sets

Patient data reports, dashboards

Documentation templates

Diagnostic support

Reference information

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

Role of Health IT in Preventing Errors

Eastern Maine Medical Center, 2008 HIMSS Davies Organizational Award


Role of health it in preventing errors2

CDS

Alerts and reminders

Clinical guidelines

Order sets

Patient data reports, dashboards

Documentation templates

Diagnostic support

Reference information

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.

Role of Health IT in Preventing Errors

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


First do no harm ensuring the safe and effective use of health it

  • 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


Unintended or unwanted consequences1

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)


First do no harm ensuring the safe and effective use of health it

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

Joint Commission Sentinel Event Alert No. 42Dec ‘08 http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm


First do no harm ensuring the safe and effective use of health it

More or new work

Extended workflow

System demands

Emotions

New kinds of errors

Power shifts

Dependence on the system

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

The Extent and Importance of Unintended Consequences Related to

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


Lessons learned unanticipated consequences

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


Human factors lessons learned unanticipated consequences

Human Factors – Lessons Learned: Unanticipated Consequences

  • 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

  • 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.

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


First do no harm ensuring the safe and effective use of health it

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 andsafety 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 safelywithin a safe workflowprocesses.


First do no harm ensuring the safe and effective use of health it

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

  • Examine workflow processes and procedures

  • Actively involve clinicians and staff

  • Assess your organization’s 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).


First do no harm ensuring the safe and effective use of health it

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


First do no harm ensuring the safe and effective use of health it

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


Alert fatigue1

Graduated system of safety alerts in the new technology that helps clinicians determine

urgency and relevancy

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

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


First do no harm ensuring the safe and effective use of health it

  • 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


First do no harm ensuring the safe and effective use of health it

  • 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


First do no harm ensuring the safe and effective use of health it

  • 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


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