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, 3-4:30pET 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. 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.

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 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

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 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).

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/SentinelEvents/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. 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

18. EMR USABILITY

19. EMR Usability • “Defining and Testing EMR Usability” • Effectiveness • Efficiency • Satisfaction • http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.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 (734) 477-0860 office (734) 604-6275 cell csmith@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. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

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. 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

36. 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

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 • 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

39. 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.

40. 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).

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/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.

43. 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

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