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Ross Koppel, Ph.D.

First Do No Harm: Ensuring the Safe and Effective Use of Health IT AHRQ HIT Conference Sept, 2009. Ross Koppel, Ph.D. Sociology Department, University of Pennsylvania & Center for Clinical Epidemiology & Biostatistics, School of Medicine, University of Pennsylvania rkoppel@sas.upenn.edu.

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Ross Koppel, Ph.D.

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  1. First Do No Harm: Ensuring the Safe and Effective Use of Health ITAHRQ HIT Conference Sept, 2009 Ross Koppel, Ph.D. Sociology Department, University of Pennsylvania & Center for Clinical Epidemiology & Biostatistics, School of Medicine, University of Pennsylvania rkoppel@sas.upenn.edu

  2. Matt’s First Assignment • Review relevant work

  3. JAMA, March 9, 2005 Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors • Ross Koppel, PhD • Joshua P. Metlay, MD, PhD • Abigail Cohen, PhD • Brian Abaluck, BS • A. Russell Localio, JD, MPH, MS • Stephen E. Kimmel, MD, MSCE • Brian L. Strom, MD, MPH

  4. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors • List of positives • Noted 22 problems, e.g.: Wrong: pt, med, dose, test-linked meds Confused dose cancelling = doubling dose when want to reduce dose Wrong dose guidance

  5. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors • Ultimate Claim: CPOE good but not good enough • Emperor not naked, but sometimes threadbare

  6. Methods • Survey • Shadowing • Interviews with leaders • Intensive interviews • Many focus groups • IT workers • Much more

  7. Reaction • Vendors • New York Times • Wall Street Journal • Washington Post • NPR • Millions of web hits • Within months, JBI devoted section of issue

  8. More Reaction

  9. Next: About 25 Articles on HIT

  10. Harrison, Koppel & Bar-Lev (JAMIA, 2007) Interactive Sociotechnical Systems Analysis

  11. Also, Harrison, & Koppel, 2009) Interactive Sociotechnical Systems Analysis

  12. Harrison, Koppel & Bar-Lev (JAMIA, 2007) Interactive Sociotechnical Systems Analysis

  13. Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety • ROSS KOPPEL, PHD, • TOSHA WETTERNECK, MD, MS, • JOEL LEON TELLES, PHD, • BEN-TZION KARSH, PHD

  14. Patient wrist barcode

  15. On every medicine

  16. 31 Causes of workarounds e.g., Unreadable medication-barcodes (crinkled, smudged, torn, missing, covered by another label) Don’t forget to scan label!

  17. Causes: • Unreadable or missing patient-ID-wristbands (chewed, soaked, missing) • Elderly, Children, Moving (unit or floor or nursing home) • Failing batteries of handheld scanners or linked computers • Difficult-to-read or navigate screens • Alert beeps that sound like confirmation beeps • Emergencies • Pharmacies sending only partial doses • About 20 others.

  18. Results 1: Fifteen identified workarounds (a) (Extra Copies) • 1 example….Reproducing patients’ wristband ID-barcodes, & affixing them to nursing station, computer cart, supply room, pt’s room doorjamb, medication dispensing machine…

  19. Results 1: Fifteen identified workarounds (b) Continued…. RN clipboard, scanner itself, in nurses’ pockets or on belt-rings, or worn as a group of bangles on nurse’s sleeve. And 14 other workarounds

  20. JAMAMarch 25, 2009

  21. Two Clauses in HIT Vendor Contracts • Who is responsible for errors? Even if hidden and embedded in the Software? And even if you are following the manual?

  22. Who can you tell? The Non-Disclosure Clause

  23. Other Recent Publications of Note • COMPARISON OF 7 NATION’S USE OF CPOE. Health Affairs • WAYS OF MEASURING MEDICATION ERRORS USING HIT. JAMIA • WEBINARS AND M&Ms ANALYSIS OF THE 80 HOUR RULE FOLLOW UP ON CPOE ANALYSIS OF MEANINGFUL USE…

  24. Matt’s Questions

  25. 1. Should the issue of EHR safety be built into the Initiatives supported in HITECH? WEARS & LEVESON

  26. 2. What should be the research agenda in this area? • Focus on quality. • But conventional methods limited.

  27. 3.    What roles should the government and private industry play? The JC? 1. I say…. 2. Others say…. 3. Industry and representatives want….

  28. The Government’s Role

  29. 4.    How do we ensure that implementations of products are done in a way that ensures safety?

  30. 5.    In what ways are vendors and healthcare organizations interacting to ensure safe and effective use of EHRs? If you build it well enough, they will want it

  31. 6.    Create a health IT usability lab. How funded? How to work it? • Yes • Funding: Gov’t, Industry and Users • Recognize it’s limited to in vitro testing. Great idea, but only a start.

  32. No. 7 (condensed) • The Health IT Extension Centers will help clinicians become meaningful users. • How can we incorporate support to ensure safe and effective use of health IT into the services that they provide? • Who else should we help?

  33. Simple Answer: Build better software: • Training faster • Less onerous • Fewer battles with counter intuitive designs

  34. Thank you! Questions? Ross Koppel, Ph.D. Sociology Department, University of Pennsylvania & Center for Clinical Epidemiology & Biostatistics, School of Medicine, University of Pennsylvania rkoppel@sas.upenn.edu

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