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Safety Task Force. June 13, 2014. Task Force Members. Meetings. U.S. National Transportation Safety Board (NTSB). David L. Mayer Managing Director. Agency for Healthcare Research and Quality (AHRQ). William B Munier, MD Director, Patient Safety Organization Program

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Safety Task Force

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    1. Safety Task Force June 13, 2014

    2. Task Force Members

    3. Meetings

    4. U.S. National Transportation Safety Board (NTSB) David L. Mayer Managing Director

    5. Agency for Healthcare Research and Quality (AHRQ) William B Munier, MD Director, Patient Safety Organization Program Center for Quality Improvement and Patient Safety

    6. Veterans Health Administration (VHA) Jeanie Scott, Director of Informatics Patient SafetyVHA Office of Informatics and Analytics/Health Informatics

    7. Health Information Technology (HIT) Safety: Veterans Health Administration (VHA) Model Presentation • HIT Policy Committee Safety Task Force – Model Presentation Jeanie Scott, CPHIMS Informatics Patient Safety Health Informatics Office of Informatics and Analytics Department of Veterans Affairs June 13,2014 6

    8. Veterans Health Information Systems and Technology Architecture (VistA) An integrated suite of Health Information Technology Systems used across care settings including: • Electronic Health Record (EHR) • Imaging • Medication Administration • Personal Health Records • Data Sharing with and beyond VHA • Much more – Administrative also…

    9. History of VA’s EHR 1977 – 1982 – Period of Central Control vs. Decentralized Clinical Innovation 1982 – Decentralized development strategy endorsed 1983: 25 sites: outpatient pharmacy, ADT*/scheduling 1985: 120 sites: Added lab, inpatient pharmacy, radiology 1989: 120 sites: Added eight additional packages 1990 – VistA Imaging 1994 – VistA Rad 1998 – Computerized Patient Record System (CPRS) 2000 – Bar Code Medication Administration (BCMA) 2007 – Indian Health Service deploys VistA Imaging *Admission/Discharge/Transfer (Registration)

    10. VistA Recognition More than 30 years experience developing medical IT solutions • 2011 Harvard University Innovations in American Government Award • 2008 “Top 100” CIO Award • 2011 Toward the Electronic Patient Record (TEPR), 1st place, Personal Health Record for My HealtheVet – VA’s personal health record • 2010 Government Technology Leadership award for VA’s BCMA program • 2013 Most Wired Award Built in partnership with clinicians, allied health and health information management professionals key to successful development and adoption.

    11. VistA VistA includes many components to deliver high-quality health care to our nation’s Veterans, including: • CPRS • VistA Imaging • BCMA • Personal Health Record - My HealtheVet

    12. CPRS Used throughout the VHA in all health care settings (inpatient, outpatient, long-term care) to deliver an integrated record covering all aspects of patient care and treatment • Key Features: • Clinical Decision Support • Documentation • Clinical Reminders • Remote Data Retrieval

    13. BCMA BCMA virtually eliminates errors at the point of administration 1994 – VA was one of the first health care organizations to develop BCMA technology to improve patient safety 1999 – Deployed to all VA Medical Centers (60,000 beds) 2003 – 100% of all VA wards documenting medication administration using BCMA 2010 - >2.8 million bar code scans observed since inception

    14. My HealtheVet A personal My HealtheVet account provides Veterans with 24/7 online access to a variety of tools to manage their health care. • Communicate with participating VA Patient Aligned Care Team members • View VA appointments and health information • Refill VA prescriptions • Download and share personal health record via the Blue Button

    15. Evolving….

    16. VA’s HIT Safety Program The VA’s Informatics Patient Safety Office analyzes HIT–related events/concerns that pose a risk to patient safety • Software Development Lifecycle Analysis • Testing processes • Deployment strategies • Implementation practices • Reporting and analysis of close calls

    17. Identification and Communication • Medication Ordering errors (LASA) - the software will auto-fill the drug name once three letters are typed. This inserts the first drug on the list with these three letters • Patient Identification Catastrophic Edits • Modifications to software • Procedure guidance ((Internal handbook) • Alerts/Advisories/Guidance documents • Order Check National Term File Mapping example • Deployment strategies • Mobile Apps – Developing an Inspection Review Process – “Identifying Latent Design Issues in Mobile Products to Prevent Patient Harm” - March 2014 Human Factors and Ergonomics Symposium

    18. Education/Awareness across Multiple Domains of Interest • Risks Associated with the Design of Electronic Medical Records -Virginia Chapter of the American Society for Healthcare Risk Management – Spring Program May 2008 • Application of Human Factors Engineering Best Practices to the Redesign of a Laboratory Information Display – May 2011 National Patient Safety Foundation conference • Risks to Patient Due to Incorrect Patient Record Selection – March 2013 Human Factors and Ergonomics Symposium • Product Vendors requests for evaluation techniques – influence external partners.

    19. Questions? Contact Information: Jeanie Scott (

    20. ECRI Institute RonniP. Solomon, J.D. Executive Vice President and General Counsel

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