Health Information Technology Patient Safety Action ... information can be ... • Improve the...

ONC Pre-decisional Draft Do not disclose

Health Information Technology Patient Safety Action amp Surveillance Plan for Public Comment December 21 2012

Health IT Patient Safety Action amp Surveillance Plan for Public Comment

Table of Contents

Introduction 3

Health IT Patient Safety Goal 5

Health IT Patient Safety Objectives 7

Health IT Patient Safety Strategies and Actions 9

Appendix A Crosswalk of Health IT Patient Safety Plan amp IOMrsquos 2011 Recommendations from Health IT and Patient Safety Building Safer Systems for Better Care 23

Appendix B Research and Development of Tools Measures and Policies 34

Appendix C Timeline of the Health IT Patient Safety Action and Surveillance Plan 36

Appendix D ONC Program 39

2


ldquoIt is widely believed that when designed and used appropriately health IT can help create an ecosystem of safer carehelliprdquo mdashInstitute of Medicine ldquoHealth IT and Patient Safety Building Safer Systems for Better Carerdquo (P 21)

Introduction

Over a decade ago the Institute of Medicinersquos (IOMrsquos) report To Err is Human raised an alarm about the failure of healthcare to recognize and reduce the large number of avoidable medical errors harming patients Health information technology (health IT) in particular electronic health records (EHRs) and health information exchange create the potential to reduce medical errors This potential is part of the reason for the creation of the Office of the National Coordinator for Health Information Technology (ONC) first by executive order in 2004 and then through the Health Information Technology for Economic and Clinical Health (HITECH) Act mdash passed as part of the American Recovery and Reinvestment Act of 2009 In addition to creating ONC the HITECH Act also provided economic incentives for eligible providers to adopt and meaningfully use certified EHR technology

The premise of these initiatives is that health IT when fully integrated into health care delivery organizations facilitates potentially enormous improvements in health care quality and safety as compared to paper records For instance

bull Medication errors can be reduced Clinical decision support (CDS) and computerized provider order entry (CPOE) provide clinicians with best practice guidance and information on the allergies and medications of specific patients as part of the clinical decision - making process With this guidance patients can also receive more of the care they require (eg immunizations or preventive care) at each clinical encounter

bull Patient records can be stored centrally and can be easily accessed from multiple locations Crucial health information can be available when needed as patients move within and between health care organizations When a patient arrives at an emergency room providers can begin treatment with immediate access to patient records

bull Health IT can be used to more efficiently report track and aggregate patient data within and across organizations This allows providers to more efficiently track and manage hospital acquired illnesses Disease outbreaks can be monitored which allows for improved population health and identification of potentially widespread threats to health such as flu epidemics

Just as health IT can create new opportunities to improve patient care and safety it can also create new potentials for harm For example poor user interface design or unclear information displays can contribute to clinicians ordering medications not appropriate for their patientsrsquo condition1 Health IT will only fulfill its enormous potential to improve patient safety if the risks associated with its use are identified if there is a coordinated effort to mitigate those risks and if it is used to make care safer Recognizing the need to identify

IOM (Institute of Medicine) 2012 Health IT and Patient Safety Building Safer Systems for Better Care Washington DC The National Academies Press Page 31

3

1


ldquoAs with any new technology health IT carries benefits and risks of new and greater harms To fully

capitalize on the potential that health IT may have on patient safety a more comprehensive

understanding of how health IT impacts potential harms workflow

and safety is neededrdquo IOM Report (P 49)

and mitigate the risks ONC commissioned an IOM study to determine how government and the private sector can maximize the safety of health IT-assisted care ldquoThe committee interpreted its charge as making health-IT assisted care safer so the nation is in a better position to realize the potential benefits of health ITrdquo2 The IOM Report Health IT and Patient Safety Building Safer Systems for Better Care was published in November 2011

This Health IT Patient Safety Action and Surveillance Plan (the ldquoHealth IT Safety Planrdquo) which builds on IOMrsquos recommendations addresses the role of health IT within HHSrsquos commitment to patient safety This plan builds upon and seeks to strengthen patient safety efforts across government programs and the private sector mdash including patients health care providers technology companies and health care safety oversight bodies HHSrsquo approach builds on existing authorities

ONC is accepting public comments on the Health IT Safety Plan Public comments will be accepted through February 4 2013 and can be emailed to ONCPolicyhhsgov Based on the public comments ONC will publish the final Health IT Safety Plan

IOM 2012 Health IT and Patient Safety Building Safer Systems for Better Care Washington DC The National Academies Press Page 2

4

2


Health IT Patient Safety Goal

Inspire Confidence and Trust in Health IT and Health Information Exchange

HHSrsquo goal is that patients and providers have confidence in the safety of the healthcare system including its health IT infrastructure based on evidence of safety Patient safety and the factors by which it is affected have been studied for decades The IOM the Agency for Healthcare Research and Quality (AHRQ) and other such organizations have contributed to a body of literature focused on patient safety Many efforts in the public and private sectors are already in place to improve patient safety and the overall quality of care

Despite a growing body of research on patient safety the IOM found ldquolittle published evidencerdquo3 quantifying the ldquoA traditional perspective on technology magnitude of risks associated with health IT In a research draws a sharp distinction between technology

and human users of the technologyhellip appendix to the IOM Report a review of seven papers [I]n the traditional perspective health ITndash using large databases of reported errors found that health related adverse events are generally not information systems were involved in less than 1 (one) recognized as systemic problems that is as percent of reported errors4 All the reviewed papers also problems whose causation or presence is

influenced by all parts of the sociotechnical point to ldquothe need for human diligence when using systemrdquo

[health information systems]rdquo The Pennsylvania Patient IOM Report (P 64) Safety Authority recently published an advisory notice outlining safety issues related to the use of EHRs and found that only 3900 of 17 million reports were found to involve health IT The vast majority of reported EHR-related events (81) involved medication errors5

Because health IT is so tightly integrated into care delivery today it is difficult to interpret this initial research which would seem to suggest that health IT is a modest cause of medical errors However it is difficult to say whether a medical error is health IT-related For example it is difficult to determine whether an error is caused by or associated with health IT if

bull A medical error could have been prevented by more sophisticated or improved implementation of CPOE or CDS or

bull A clinician does not use certain health IT functionality that could have prevented an error because the functionality was frustrating or inefficient to use

Additionally EHR adoption in the past has been low This means the lack of patient harm attributed to health IT may not be due to how safe health IT is but to its lack of use6 However as EHR adoption

3IOM (Institute of Medicine) 2012 Health IT and Patient Safety Building Safer Systems for Better Care Washington DC The National Academies Press Page 3 (Available at httpwwwiomeduReports2011Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Careaspx) Id Appendix C page 186

5Pennsylvania Patient Safety Authority The Role of Electronic Health Record in Patient Safety Events httpwwwpatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012Dec9(4)Pages113aspx (last accessed 121912)

5

4

becomes more widespread the opportunity for harm may also increase The increase in EHR adoption also creates a unique opportunity to improve patient safety For example EHRs can

bull Increase cliniciansrsquo awareness of potential errors and adverse interactions

bull Improve the availability and timeliness of information to support treatment decisions care coordination and care planning

bull Make it easier for clinicians to report safety issues and hazards and

bull Give patients the opportunity to more efficiently provide input on data accuracy than what paper records would allow

6 For example the Pennsylvania Patient Safety Authorityrsquos Advisory Notice found that only 3900 of 17 million reports involved health IT However the database that the 17 million reports were collected from began collecting reports in 2004 when the rate of EHR adoption was minimal Pennsylvania Patient Safety Authority The Role of Electronic Health Record in Patient Safety Events httpwwwpatientsafetyauthorityorgADVISORIESAdvisoryLibrary2012 Dec9(4)Pages113aspx (last accessed 121912)

6 Health IT Patient Safety Action amp Surveillance Plan for Public Comment


Health IT Patient Safety Objectives

1 Use health IT to make care safer 2 Continuously improve the safety of health IT

This Health IT Safety Plan has two fundamental objectives first to promote the health care industryrsquos use of health IT to make care safer and second to continuously improve the safety of health IT itself

ldquoAn environment of safer health IT can be created if

both the public and private sectors acknowledge that

safety is a shared responsibilityrdquo

IOM Report (P 125)

Achieving these objectives is a shared responsibility No one entity or group can fully realize the potential of health IT to improve patient safety Instead the Health IT Safety Plan aims to coordinate the actions required of the different actors in the health IT and patient safety community including but not limited to

bull Clinicians bull Care Delivery Organizations including

o Administrators o IT staff o Quality improvement staff

bull Patients and their caregivers bull Federal and state governments bull Health IT developers bull Patient safety organizations bull Accrediting bodies bull Other organizations and stakeholders including

o Liability insurers o Educational organizations o Health insurers o Professional associations o Publishers

Use health IT to make care safer

The Departmentrsquos National Quality Strategy7 incorporates the goals of the Partnership for Patients8 which aims to reduce hospital acquired conditions and avoidable hospital readmissions Health IT creates an infrastructure for identifying and monitoring patient safety events in these areas making it possible to deploy more effective clinical decision support and other health IT to help achieve health and safety objectives Hospital-acquired conditions and adverse events targeted in the Partnership for Patients program can be the focus for CDS resulting in decreased harm to patients Examples of CDS that can be integrated into EHRs include standardized checklists to prevent central venous catheter associated bloodstream infections criteria for verification of the proper position of catheters and notifications to discontinue medications or other interventions For venous thromboembolism (VTE) a risk assessment linked to an order set of preferred

7 National Quality Strategy httpwwwahrqgovworkingforqualityindexhtml (last accessed on December 6 2012) 8 Partnership for Patients Better Care Lower Costs httpwwwhealthcaregovcomparepartnership-for-patients (last

accessed on December 6 2012)

7


VTE prophylaxis methods can potentially diminish the risk of development of hospital acquired VTE Standardized order sets have also been implemented in labor and delivery setting and demonstrated significant reductions in obstetrical adverse events CDS enables electronic integration of protocols to prevent injury from falls or pressure ulcers such as risk assessments or prompts to revaluate the patientrsquos risk with a change in status or upon transfer

CDS also enhances the safety of e-Prescribing by providing drug - drug interaction notifications and drug ndash allergy warnings which have been shown to decrease adverse drug events These adverse events can be further reduced using additional CDS which support drug ndash medical condition notifications triggers for lab results indicating risk for adverse drug events and medication treatments One of the most common medication errors involves improper dose or quantity CDS can often be used to identify these errors early in the prescribing process and can mitigate or prevent harm before it reaches the patient

HHS has already taken steps toward improving patient safety through health IT For example EHR payment incentive requirements mdash such as maintaining lists of patient medications allergies and problems and the use of computerized provider order entry (CPOE) mdash are tangible steps towards growing a safety infrastructure

Continuously improve the safety of health IT

The purpose of this objective is to ensure that when physicians nurses therapists and other clinical users of health IT care for patients they are using a safely designed and implemented system are properly informed and trained to use the health IT system are using that system safely and have processes in place to identify and correct unsafe conditions or unsafe uses of health IT

CPOE and CDS which have the enormous potential to help avoid medical errors must be safely designed tested implemented supported and used correctly The content must be accurate up-to-date clinically relevant and the functionality must be easy to use in efficient clinical workflows Providers must be trained to use the systems properly and effectively This objective ensures a focus on continuously improving the safety of health IT so that it enables providers to deliver high quality care safely

8


Health IT Patient Safety Strategies and Actions

Increase the quantity and quality of data and knowledge about health IT safety

Learn

The proper steps to improve the safety of health IT can only be taken if there is better information regarding health ITrsquos risks harms and impact on patient safety The Health IT Safety Plan will improve knowledge on the types frequency and severity of health IT-related patient safety events It also aims to use health IT as a tool to facilitate the reporting of patient safety events in general The following steps are designed to

bull Establish mechanisms that facilitate reporting among users and developers ldquoTo fully capitalize on the potential that

health IT may have on patient safety a more bull Assist Patients Safety Organizations (PSOs) ONC- comprehensive understanding of how health IT

Authorized Certification Bodies (ONC-ACBs) and Centers impacts potential harms workflow and safety for Medicare amp Medicaid Services (CMS) surveyors in is neededrdquo identifying and addressing health IT-related safety issues IOM Report (p 49)

bull Aggregate and analyze data on health IT-related safety events

1 Make it easier for clinicians to report patient safety events and risks using EHR technology

To understand the impact of health IT on patient safety clinicians must collect data on how health IT functions in real clinical environments Clinicians reporting adverse events and risks that are perceived to be related to health IT provides the raw data necessary for developers providers researchers and policymakers to understand the root causes of such events and subsequently improve health IT While caring for patients health care providers should be able to use EHRs to easily initiate patient safety reports at the time of discovery or occurrence ONC intends to propose using certification criteria to ensure that where appropriate EHR technology can facilitate reporting of safety events in AHRQrsquos Common Formats

9


9

AHRQrsquos Common Formats are a reporting tool that standardizes and promotes increased reporting of adverse events near misses and unsafe conditions9 The most recent version of the Common Formats includes a ldquoDevice with Health ITrdquo format that allows collection of standardized information about IT-related adverse events as well as events where health IT may be a contributing factor The Common Formats have the goal of improving the efficiency of patient safety reporting by enabling one - time data collection and subsequent routing to whomever needs or requests the data The Common Formats also provide local facility reporting capabilities for rapid identification of quality and safety problems and for the facilitation of changes to address the problems The Common Formats also make it possible to aggregate and compare adverse events across care delivery organizations and federal and state programs

To help inform ONCrsquos work with standards and certification criteria related to patient safety AHRQ plans to support research that will explore extraction of data elements identical and related to AHRQrsquos Common Formats from multiple established EHR implementations and exportation of this data to hospital incident reporting systems

ONC recently funded a Patient Safety Reporting Challenge Award to address the need for development of software tools and interfaces that decrease adverse event reporting burden incorporate the Common Formats to enable aggregation and consistency in reporting and improve workflow efficiency regarding adverse event reporting to healthcare organizations Three winners of this award were announced in November 201210 ONC expects these and similar tools to become much more widely used to help organizations build a culture of safety11 that includes adverse event reporting and follow-up

In response to recent HHS Office of the Inspector General reports on adverse events in hospitals AHRQ has already taken steps to promote increased reporting of all adverse events near misses and unsafe conditions using the AHRQ Common Formats12 This includes patient safety events related to health IT and using Patient Safety Organizations (PSOs)13 to report analyze and mitigate these events

AHRQ Common Formats httpwwwpsoahrqgovformatscommonfmthtm (last accessed 121512) 10 Challengegov Reporting Patient Safety Events httpchallengegovONC349-reporting-patient-safety-events (last

Accessed 121612) 11 AHRQ Safety Culture httppsnetahrqgovprimeraspxprimerID=5 (last accessed October 30 2012) (ldquoA culture

of safety encompasses the following key features acknowledgment of the high-risk nature of an organizations activities and the determination to achieve consistently safe operations a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems organizational commitment of resources to address safety concerns)

12 OIG (Office of the Inspector General) Report (OEI-06-09-00091) Hospital Incident Reporting Systems Do Not Capture Most Patient Harm httpsoighhsgovoeireportsoei-06-09-00091asp (last accessed 11212) See also infra Learn Step 3 for ONCrsquos plan to promote use of PSOs by providers

13 The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorized the creation of Patient Safety Organizations (PSOs) to improve the quality and safety of US health care delivery The Patient Safety Act encourages clinicians and health care organizations to voluntarily report and share quality and patient safety information without fear of legal discovery

10


2 Engage health IT developers to embrace their shared responsibility for patient safety and promote reporting of patient safety events and risks

The Electronic Health Record Associationrsquos (EHRA) Statement of Commitment to Patient Safety and Learning Healthcare System is a first step in ensuring that developers embrace a shared responsibility and support a culture of safety14 ONC will work with EHRA health IT developers and other professional groups to develop a code of conduct ndash within 12 months of the release of this Health IT Patient Safety Plan ndash that is aligned with a credible mechanism for holding health IT developers accountable At a minimum this code of conduct should

bull Ensure business practices are in place to promote the usability and safety (safe design) of health IT products and adverse event reporting

bull Ensure health IT developers work with a PSO15 or a similar entity to report aggregate and analyze health IT-related safety events Developers should collaborate and provide safety information related to their product for the purposes of improving patient safety Currently the patient safety work product (PSWP) protections16 do not extend to developers reporting events to PSOs However HHS believes there may be ways developers can mitigate risks of reporting HHS will monitor this and would consider suggestions on how to expand PSWP protections

bull Support provider reporting of safety events The IOM identified legal (contractual nondisclosure clauses and intellectual property protections) and other factors that may inhibit the free exchange of information to be a potential barrier to patient safety and transparency Although ONC recognizes the importance of contractual and intellectual property protections it also recognizes that many EHR users may be deterred from exchanging information or from reporting if those contract provisions are not qualified or clarified to encourage such activities Most patient safety event reporting does not violate such protections and developers should not use such protections to prevent users from reporting patient safety - related events

bull Ensure developers cooperate with efforts to compare user experiences accross different EHR systems Publicly available information on comparative user experience can help health IT purchasers make more informed choices related to the safety of products

ONC will monitor developers progress towards these goal and ensure that they are complying with their commitments to a culture of safety

14 Electronic Health Record Association Statement of Commitment to Patient Safety and Learning Healthcare System httpwwwhimssehraorgdocs20120221 EHRAPatientSafetyStatementofCommitmentpdf (last accessed 11112)

15 AHRQ Patient Safety Organizations httpwwwpsoahrqgov (last accessed 12172012) 16 Office of Civil Rights (OCR) Understanding Patient Safety Confidentiality httpwwwhhsgovocrprivacypsa

understandingindexhtml (last accessed 12202012)

11


In addition to the code of conduct ONC will work with private organizations developers and providers to make more health IT ndash related safety information available Workgroups or common interest groups that focus on health IT and safety could be established at professional forums such as the Healthcare Information and Management Systems Society (HIMSS)17 or the American Medical Informatics Association (AMIA)18 to help educate developers and users on how to identify and report adverse events the benefits of using Common Formats and working with PSOs

3 Provide support to Patient Safety Organizations (PSOs) to identify aggregate and analyze health IT safety event and hazard reports

AHRQ will provide technical assistance on using Common Formats rendering patient safety event data non-identifiable (as needed) and making health IT ndash related patient safety reports available in the Network of Patient Safety Databases (NPSD)19 AHRQ will encourage PSOs to help providers use AHRQ Common Formats when submitting health IT - related patient safety events to PSOs This will allow PSOs to more efficiently identify aggregate and analyze health IT ndash related patient safety reports AHRQ also funds a technical assistance center for PSOs -the PSO Privacy Protection Center (PSO ndash PPC) an entity that makes information that is collected by the PSOs nonidentifiable and submits the nonidentified data to the NPSD20 The NPSD will analyze reported events that are related in some way to the use of health IT or that can be avoided or mitigated by more effective use of health IT HHS will publish a report of its findings To complement aggregate analysis done at the NPSD PSOs and individual hospitals can conduct both aggregate analysis and in-depth analysis on individual events using the Common Formats

To improve the ability to analyze data and collaboratively address health IT ndash related safety issues AHRQ will issue guidance on how all stakeholders can incorporate health IT expertise and collaborate for the purposes of analyzing and correcting health IT ndash related adverse events trends and risks ONC will encourage PSOs providers and developers to work with private

17 HIMSS httpwwwhimssorg (last Accessed 12192012) 18 AMIA httpwwwamiaorg (last Accessed 12192012) 19 Network of Patient Safety Databases httpwwwpsoahrqgovnpsdnpsdhtm (last accessed 11292012) 20 The PSO Privacy Protection Center httpswwwpsoppcorg (last accessed 12202012)

12


organizations that already have experience collaborating with and analyzing safety issues in other industries such as aviation

4 Incorporate health IT safety in post-market surveillance of certified EHR technology through ONC-Authorized Certification Bodies (ONC-ACBs)

ONC will work with ONC-ACBs and the ONC-Approved Accreditor (currently the American

certification program

ONC will provide guidance re-garding 1) developers keeping a record of complaints 2) making complaint records available to the certification body upon re-quest 3) taking appropriate action with respect to com-plaints and 4) documenting actions taken ONC will also provide guidance to ONC-ACBs on reviewing complaints safety issues related to capabilities for which certification is required and the type and level of infor-mation included in the annual surveillance report submitted to ONC

ONC expects that ONC-ACBs will conduct surveillance to ensure that the capabilities of certified EHR technology work in operational settings (in the field or in a live environment) to the same extent as when they were certified and ONC-ACBs could review and validate a sample of the complaints EHR technology developers receive

In reporting its surveillance results to ONC an ONC-ACB will be expected to indicate whether the EHR technology was functioning in a manner consistent with its certification and if not the reasons why it was not functioning in this manner (eg implementation error a misapplication by a user or other factors) ONC will provide more specific guidance to the ONC-ACBs in coordination with ANSI for conducting surveillance under the ONC HIT Certification Program

5 Align CMS health and safety standards with the safety of health IT and train surveyors

CMS plans to align its health and safety standards for providers and suppliers and its interpretive guidance as needed related to the safety of health IT with this Health IT Safety Plan Working with ONC CMS plans to also develop training for surveyors that enhances their ability to identify safe and unsafe practices associated with health IT

National Standards Institute (ANSI)) to add a focus on health IT safety surveillance through ONCrsquos

13


State survey agencies conduct thou-sands of complaint investigation surveys on CMSrsquo behalf each year When surveys identify deficient practices providers and suppliers must submit to CMS a plan of cor-rection for achieving compliance

The Medicare health and safety standards for many types of health care facilities already address areas of patient safety in which health IT is critical For example the Hospital Conditions of Participation (CoPs) include a requirement for each hos-pital to have a Quality Assessment and Performance Improvement program that includes internal ad-verse incident reporting and effective follow - up By using health IT to promote effective reporting and follow - up health IT can make patient care safer overall as well as identify and improve patient safety issues related to health IT itself For instance hospitals are required un-der the CoPs to track adverse drug events Insomuch as health IT may be one cause of a medication error the hospitalrsquos incident reporting system should be able to identify the error and its potential causes This is true of many of the other areas addressed in the Medicare health and safety standards

Additionally CMS is currently educating its surveyors to look for use of the AHRQ Common Formats in hospitalsrsquo internal adverse incident reporting systems

6 Collect data on health IT safety events through the Quality amp Safety Review System (QSRS)

AHRQ is currently building the Quality amp Safety Review System (QSRS) a replacement for the Medicare Patient Safety Monitoring System (MPSMS) which incorporates the AHRQ Common Formats to broaden the surveillance to harm from all causes

The QSRS a software system designed to perform retrospective surveillance for adverse events and scheduled for completion in 2014 will provide national estimates of adverse events using the Common Formats and can explore the role of health IT in these events QSRS software will initially be deployed at the CMS Clinical Data Abstraction Center and is being designed for use on a voluntary basis by local entities such as states hospital networks or individual hospitals

Since the QSRS will not be completed until 2014 in the interim AHRQ intends to support research that will provide better estimates of the frequency type and harm level occurring with adverse

14


events related to health IT Additionally while the QSRS is under development AHRQ has added a new query to the MPSMS For 2012 data MPSMS abstractors will identify which patient records in the sample are from EHRs paper records and mixed records This may provide insight into whether the incidence of the combined rate of adverse events measured by MPSMS is different varies with levels of health IT integration

7 Monitor health IT adverse event reports to the Manufacturer and User Facility Device Experience (MAUDE) database

ONC will monitor health IT adverse event reports to the FDA MAUDE database21 to identify potential trends of health IT patient safety risks MAUDE is a searchable database of adverse event reports on devices containing data that includes voluntary reports user facility reports and device manufacturersrsquo reports

21 MAUDE - Manufacturer and User Facility Device Experience httpwwwaccessdatafdagovscriptscdrhcfdocscfmaudesearchcfm

15



Target resources and corrective actions to improve health IT safety and patient safety

Improve

IOMrsquos 1999 report To Err is Human states that the use of information technology can improve patient safety through automated order entry clinical reminders and drug - drug interaction and drug - allergy checking22

When clinicians managers and health care executives and board members act to reduce hospital acquired conditions and avoidable readmissions health IT can be an essential tool to support those efforts Compared with paper based systems health IT provides an efficient mechanism to identify problem areas monitor changes in those areas measure success and implement improvements

While the magnitude of establishing such a national infrastructure was hard to imagine in 1999 the Medicare and Medicaid EHR Incentive Program is a realization of that goal As of September 2012 more than 150000 providers met the criteria to receive CMS Medicare or Medicaid EHR Incentive Program payments 80 percent of eligible hospitals (4057 hospitals) successfully registered for the incentive program 55 percent of Medicare eligible professionals (208331 eligible professionals) have successfully registered and 94741 Medicaid eligible providers have also successfully registered in 44 states

1 Use Meaningful Use of EHR technology to improve patient safety

HHS has already taken steps toward this end through the Medicare and Medicaid EHR Incentive Program and the ONC regulations for certified EHR technology This program directly addresses ldquothe absence of real progress toward restructuring health care systems to address both quality and cost concerns or toward applying advances in information technology to improve administrative and

22 IOM To Err Is Human Building a Safer Health System Washington DC The National Academies Press 2000 (available at httpwwwiomeduReports1999To-Err-is-Human-Building-A-Safer-Health-Systemaspx)

16


clinical processesrdquo23 For example EHR payment incentive requirements such as maintaining lists of patient medications allergies and problems as well as the use of computerized provider order entry (CPOE) are very tangible elements of a growing safety infrastructure As part of a request for public comment on Meaningful Use Stage 3 the HIT Policy Committee is seeking comments on whether there should be a Meaningful Use requirement for providers to conduct a health IT safety risk assessment

Health IT products provide inherent safety advantages over paper records in that patient record is rarely physically lost is legible is rapidly available in multiple locations and often provides clinical decision support But just as paper records can be incomplete inaccurate and inaccessible so can electronic records compromising their safe use ONC plans to work with its federal advisory committees determine ways to improve clinical documentation thereby reducing the risk that records will be inaccessible or their accuracy or completeness compromised

2 Incorporate safety into certification criteria for health IT products

Features mdash such as CPOE functions and maintaining lists of patient medications allergies and medical conditionsmdash are already requirements for EHR certification The safety of EHR developer products and services can be improved by encouraging the development and adoption of recognized industry standards for usability and quality management processes can further ensure

As part of the 2014 Edition Standards and Certification Criteria final rule ONC adopted two enhanced certification criteria drawn from IOM recommendations Certified EHR technology developers will be required to publicly identify a method of incorporating user - centered design of eight certification criteria that have a high likelihood of helping to prevent medical errors24 IOM characterized this type of user - centered design as a way of making ldquothe right thing to do the easy thing to dordquo25 Certified EHR technology developers will also be required to provide transparency regarding their approach to ldquoquality management systemsrdquo26 which IOM characterized as ldquodriving performance characteristics at each level to make sure that the product and specifications are in line with the usersrsquo needs and expectationsrdquo27 ONC intends to continue using its standards and certification criteria and certification program rulemaking in ways that enhance health IT patient safety focusing on human factors safety culture and user - centered design

23 IOM Crossing the Quality Chasm A New Health System for the 21st Century Page 3 Washington DC The National Academies Press 2001 (Available at httpwwwiomeduReports2001Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Centuryaspx)

24 77 Fed Reg 54186-54189 (September 4 2012) 25 IOM (Institute of Medicine) 2012 Health IT and Patient Safety Building Safer Systems for Better Care Washington DC The

National Academies Press Page 81 See Chapter 4 Opportunities to Build a Safer System for Health IT 26 77 Fed Reg 54189-54191 (September 4 2012) The final rule gives CEHRT developers the option during Stage 2 to

satisfy this certification criteria by publicly declining to identify a quality management system program used in software development

27 IOM Report at 143

17


3 Support research and development of testing user tools and best practices related to health IT safety and its safe use

The National Institute for Standards and Technology (NIST) with support from ONC has developed tools for usability testing of certified EHR technology Building from NISTrsquos work the Strategic Health IT Advanced Research Projects - C (SHARP - C) Program is developing usability testing tools ONC and NIST will continue to build on this work and ONC may use it to strengthen safety-enhanced certification criteria

ONC AHRQ and NLM are each supporting development and piloting of different interventions and tools aimed at improving health IT safety and evaluating the effectiveness of those tools in hospitals and provider practices (eg Hazard Manager Promoting Patient Safety through Effective Health IT Risk Management SAFER Guides Workflow Assessment for Health IT Toolkit Guide to Reducing Unintended Consequences of Electronic Health Records Implementation Toolsets for E-Prescribing ndash see also Appendix A) AHRQ already has a portfolio of useful tools and reports for addressing the potential safety issues that arise when implementing and using EHRs

The accurate and efficient matching of patients to their health information is critical to ensuring patient safety Incorrect matching can result in misinformation and medical error In 2013 ONC is moving ahead on recommendations to improve patient matching including approaches that address workflow issues data quality functional and technical requirements data standards and policy

ONC is also conducting analysis using CMS and AHRQ datasets to determine the association between health IT and adverse drug events and the association between meaningful use and hospital acquired conditions

4 Incorporate health IT safety into medical education and training for all health care providers

Accrediting bodies patient safety organizations liability insurers educational organizations and professional associations should support an open culture of safety and integrate health IT patient safety into their programs and practices

To that end ONC will work with the organizations to foster a culture of safety and the dissemination of best ndash in - class tools and strategies to effectively reduce health IT related adverse events and to use health IT to make care safer

As part of an ONC contract on Anticipating Unintended Consequences28 health IT safety researchers29 are developing health IT safety guides Safety Assurance Factors for EHR Resilience (SAFER) Guides The SAFER Guides mdash which are being developed based on existing research expert opinion stakeholder engagement and field work mdash should enable everyone who is

28 Westat Task Order HHSP23337003THHSP23320095655WC Unintended Consequences of Health IT and HIE

29 Dean Sittig University of Texas at Houston Hardeep Singh MD Baylor University and VA Joan Ash Oregon Health and Science University

18


responsible for safety in health systems and ambulatory settings to implement safety programs for health IT in critical areas30

5 Investigate and take corrective action when necessary to address serious adverse events or unsafe conditions involving EHR technology

Reports of specific adverse events or patterns of serious events must trigger investigations and when appropriate corrective actions

The IOM recommended establishing a new federal entity similar to the National Transportation Safety Board (an independent federal agency charged by Congress with investigating every civil aviation accident the United States) HHSrsquo approach builds on existing Federal authorities (eg CMS AHRQ and ONC)

HHS is also interested in working with private sector organizations that have the ability to investigate take corrective actions and publicly report on their analysis of events

CMS plans to provide guidance to state surveyors and accreditation organizations with CMS-approved programs so that these entities can recognize and investigate health IT ndash related adverse events Accreditation organizations and surveyors should conduct investigations when necessary to determine the causes of adverse events or unsafe conditions involving EHR technology

ONC will work with developers to request voluntary corrective action when HHS becomes aware of a potential serious safety risks through the programs described in this Health IT Safety Plan HHS will consider issuing public notices related to serious adverse events or unsafe conditions involving EHR technology

30 SAFER Guides are being developed in the following areas inpatient ordering process and computerized provider order entry (including for medications laboratory tests radiology nutrition etc) ambulatory physician practice medication ordering process e-Prescribing inpatient and outpatient system customizationconfiguration and upgrades systemndashsystem interfaces both inpatient and ambulatory patient identification processes both inpatient and ambulatory clinical decision support inpatient and ambulatory communication between providers ndash ambulatory physician practice and hospital discharge laboratory results review processes ndash ambulatory physician practice and hospital discharge downtime events both inpatient and ambulatory roles and skills of people needed for EHR safety both inpatient and ambulatory

19



Promote a culture of safety related to health IT

Lead

Leadership is essential to building high reliability organizations with strong safety cultures HHS has already taken a leadership role by promoting adoption and meaningful use of health IT to improve health care safety and outcomes

This Health IT Safety Plan lays out concrete steps to improve federal coordination and integrate health IT patient safety into existing federal programs It also outlines how HHS plans to collaborate with the private sector to promote patient safety in a health IT enabled care delivery system

1 Develop health IT safety priority areas measures and targets

ONC plans to lead a public - private process to identify health IT safety priority areas within that larger context general patient safety and create related measures and targets for reduction of health IT ndash related adverse events

ONC has already initiated research that will inform this process by contracting to develop health IT safety guides (ie SAFER Guides) and to pilot test and evaluate health IT risk management interventions in hospitals and ambulatory settings (ie Promoting Patient Safety Through Effective Health IT Risk Management)31 (see Appendix B for more research and development of guides tools and interventions) The SAFER Guides will be a checklist tool available to all providers to use in assessing and mitigating risks related to health IT

31 Rand Corporation Task Order HHSP23337026T

20


2 Publish a report on a strategy and recommendations for an appropriate risk-based regulatory framework for health IT

Congress passed the FDA Safety and Innovation Safety Act of 2012 This Act tasked the FDA ndash in collaboration with ONC and the Federal Communications Commission (FCC) ndash with creating a report within 18 months which proposes a strategy and recommendations for an appropriate risk-based regulatory framework for health IT which promotes safety and innovation This report will be developed with significant public input and will incorporate what HHS learns about risk safety and opportunity for innovative technologies to support improved health outcomes

It is clear that there are opportunities to consider how to make it easier for innovators to understand the regulatory landscape ways to minimize regulatory burden ndash such as the complexity of navigating numerous agencies and to design an oversight approach that supports innovations and patient safety

3 Establish an ONC Safety Program to coordinate the implementation the Health IT Safety Plan

ONC plans to establish an ONC Safety Program to coordinate and implement this Health IT Safety Plan (See figure in Appendix D) The function of this program is to

bull Coordinate the implementation of the Health IT Safety Plan by o Ensuring all actors are fulfilling their responsibilities under the Plan o Collaborating with actors to incorporate health IT and patient safety in their

organizations bull Comprehensively analyze data from the data streams which includes

o Collecting and aggregating data among the different data streams o Identifying trends in patient safety and health IT o Providing feedback to developers and providers o Submitting policy recommendations to government agencies and Congress

bull Eliminate or significantly reduce inefficiencies across the programs by o Identifying any unnecessary overlap that occurs when implementing the Health

IT Safety Plan o Evaluating the outcomes and effectiveness of the Health IT Safety Plan as it is

implemented o Determining from the outcomes what actions are beneficial unnecessary or

insufficient (and whether additional actions are required)

Although led and run by ONC this program will work with and gather input from federal partners mdash including AHRQ CMS FDA and OCR32 mdash to accomplish the above goals Also HHS will

32 OCR administers the HIPAA Security Rule which sets national standards for the confidentiality integrity and availability of electronic protected health information These are key components to addressing health IT patient safety OCR has also been delegated responsibility for enforcing the confidentiality provisions of the Patient Safety and Quality Improvement Act (PSQIA)

21


develop policies and procedures to establish an ad hoc HHS multi-Agency steering committee to address major health IT safety issues

4 Encourage state governments to incorporate health IT into their patient safety oversight programs

State governments play a vital role in patient safety oversight In some cases federal and state patient safety programs are aligned such as the coordination of Medicare and Medicaid on health and safety standards required for participation in those programs States also license health care professionals and facilities In addition 26 states have mandatory adverse event reporting laws requiring in certain circumstances reporting of adverse events to the state

AHRQ has encouraged states to use the Common Formats to make it possible to aggregate and compare adverse events across federal and state programs Today state adverse event reporting programs do not identify the role health IT may play in patient safety including in monitoring reporting and improving care processes HHS will encourage state involvement in the public-private process to refine health IT patient safety priorities measures and targets Also HHS will coordinate with state governments to effectively integrate health IT into existing patient safety efforts

5 Encourage private sector leadership and shared responsibility for health IT patient safety (IOM Report Chapter 6 Shared Responsibility for Improving Health IT Safety)

All stakeholders have an interest in ensuring that health IT is safe and that health IT enhances patient safety The Health IT Safety Plan aims to engage and align private sector efforts Clinical users of health IT and health IT developers are primarily responsible for ensuring patient safety with full support and engagement of professional and trade associations medical educators liability insurers and private organizations supporting patient safety

Throughout the Health IT Safety Plan HHS identifies ways that private sector stakeholders can lead critical efforts to improve health IT safety

22


Appendices

Appendix A Crosswalk of Health IT Patient Safety Plan amp IOMrsquos 2011 Recommendations from Health IT and Patient Safety Building Safer Systems for Better Care

IOM Recommendation Actions

Recommendation 1

The Secretary of Health and Human Services (HHS) should publish an action and surveillance plan within 12 months that includes a schedule for working with the private sector to assess the impact of health IT on patient safety and minimizing the risk of its implementation and use The plan should specify

This Health IT Patient Safety Plan is the action and surveillance plan prescribed in Recommendation 1 ONC will coordinate the various actors among the public and private sectors to improve the safety of health IT and use health IT to improve patient safety

Recommendation 1a

The Agency for Healthcare Research and Quality (AHRQ) and the National Library of Medicine (NLM) should expand their funding of research training and education of safe practices as appropriate including measures specifically related to the design implementation usability and safe use of health IT by all users including patients

ONC AHRQ and NLM are disseminating and piloting interventions and tools aimed at improving health IT safety and evaluating the effectiveness of those tools in hospitals and provider practices (eg Hazard Manager Promoting Patient Safety through Effective Health IT Risk Management SAFER Guides) AHRQ already has a significant portfolio of useful tools and reports for addressing the potential safety issues that arise when implementing and using EHRs including the following

bull Hazard Manager is a software tool that will alert users to potential health IT-related patient safety events It evaluates near misses and unsafe conditions which allows users to avoid patient harm before it occurs Although not yet available the Hazard Manager will support a wide variety of health industry professionals by helping them discover identify and communicate hazards

bull Promoting Patient Safety through Effective Health IT Risk Management bull SAFER Guides

23



Recommendation 1 a continued bull Workflow Assessment for Health IT toolkit available at wwwhealthitahrqgovworkflow is designed to help small and medium-sized outpatient practices better assess their workflows and determine when and how health IT may be used This comprehensive compendium of information describing workflow in the context of health IT includes

o information on how to analyze workflow o tools to analyze workflow o examples of workflow analysis and redesign o othersrsquo experiences with health IT and workflow and o research on health IT and workflow

Recommendation 1 a continued bull Guide to Reducing Unintended Consequences of Electronic Health Records ndash an online resource posted on healthITgov that helps organizations and their consultants anticipate avoid and troubleshoot problems and challenges that can emerge when implementing and using an electronic health record (EHR)

Recommendation 1 a continued bull Implementation Toolsets for E-Prescribing ndash These two toolsets one for physicians in small practices and one for independent pharmacies for supporting e-prescribing implementation are designed to offer a step-by-step guide preparing for and launching an e-prescribing system They include advice on topics ranging from planning the implementation process launching the system troubleshooting common problems and navigating into more advanced practice and pharmacy services Both toolsets and supporting tools are available at httphealthitahrqgoveprescribingtoolsets

24



Recommendation 1 a continued ONC will coordinate with liability insurers educational organizations and professional associations to foster a culture of safety and the dissemination of best-in-class tools and strategies to effectively reduce health IT related adverse events and to use health IT to make care safer As part of an ONC contract on Anticipating Unintended Consequences33 health IT safety researchers34 are developing health IT safety guides Safety Assurance Factors for EHR Resilience (SAFER) Guides

Recommendation 1b

The Office of the National Coordinator for Health Information Technology should expand its funding of processes that promote safety that should be followed in the development of health IT products including standardized testing procedures to be used by manufacturers and health care organizations to assess the safety of health IT products

The National Institute for Standards and Technology (NIST) with support from ONC has developed tools for usability testing of certified EHR technology NIST and ONC will continue to build upon this work and ONC will use it to strengthen safety-enhanced certification criteria

The Strategic Health IT Advanced Research Projects ndash C (SHARP -C) Program is developing usability testing tools using NIST protocols

Recommendation 1c

The ONC and AHRQ should work with health IT vendors and health care organizations to promote post deployment safety testing of EHRs for high-prevalence high-impact EHR-related patient safety risks

The Plan calls for ONC to inform ONC-ACBs of our surveillance priorities in order identify those EHR technology capabilities that ONC believes pose the greatest potential for patient harm and greatest opportunity to improve in future regulatory cycles ONC will encourage ONC-ACBs to conduct surveillance to ensure that these capabilities work in operational settings and validate a sample of the complaints EHR technology developers



25



Recommendation 1d

Health care accrediting organizations should adopt criteria relating to EHR safety

ONC will work with CMS to align the health and safety standards with the Health IT Safety Plan and train surveyors to improve their ability to identify safe and unsafe practices related to health IT

States in enforcing the existing health and safety regulatory standards investigate complaints on CMSrsquo behalf CMS can require corrective action (as needed) for these standards related to the safety of health IT

ONCrsquos regulations establish standards and certification criteria for certified EHR technology and ONC intends to use certification criteria to ensure that where appropriate EHR technology is used to report safety events

Recommendation 1e

AHRQ should fund the development of new methods for measuring the impact of health IT on safety using data from EHRs

AHRQ has developed ldquoCommon Formatsrdquo which would standardize the reporting of adverse events These Formats make it possible to aggregate and compare adverse events across healthcare providers and federal and state programs

The most recent version of the Formats includes a ldquoDevice with Health ITrdquo format that allows collection of standardized information about IT-related adverse events as well as all events where health IT may be a contributing factor

AHRQ is currently building the Quality amp Safety Review System (QSRS) that incorporates the AHRQ Common Formats to broaden the surveillance of harm from all causes This system will provide national estimates of adverse events and can explore the role of health IT in these events

26



Recommendation 2

The Secretary of HHS should ensure insofar as possible that health IT developers support the free exchange of information about health IT experiences and issues and not prohibit sharing of such information including details (eg screenshots) relating to patient safety

ONC will engage developers and facilitate the development of a voluntary code of conduct that ensures business practices are in place that promote adverse event reporting

As part of the ONC HIT Certification Program ONC established the Certified HIT Product List (CHPL) The CHPL provides the comprehensive listing of Complete EHRs and EHR Modules that have been certified by ONC-Authorized Certification Bodies (ONC-ACBs) This listing is a publicly available database of health IT products that are certified in accordance with ONCrsquos standards and certification criteria regulations Currently each individual EHR product listed in the database notes the presenceabsence of safety features such as drug - drug interaction or drug- allergy checking ONCrsquos newest certification criteria also require developers to incorporate user centered design and these details will be included in EHR technology test reports If there is a need for further registration and listing to promote transparency related to the safety of health IT beyond ONCrsquos existing CHPL ONC will consider using its current authorities to broaden the list

ONCndashACBs are required to submit a hyperlink of the test results used to issue a certification to EHR technology that are publicly accessible

27



Recommendation 3

The ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available

ONC will support and collaborate with the private sector to publish information on comparative user experiences

The Plan will encourage AHRQ and Patient Safety Organizations (PSOs) to increase data collection and analysis of health IT safety events and hazards PSOs will work with providers to report adverse events involving health IT using the AHRQ Common Formats and to report those events to the Network of Patient Safety Databases (NPSD)

The Plan also calls for EHR developers to facilitate and encourage adverse event reporting using the AHRQ Common Formats and allow for the reporting of comparative user experiences related to the safety and reliability of health IT

28


Recommendation 4

The Secretary of HHS should fund a new Health IT Safety Council to evaluate criteria for assessing and monitoring the safe use of health IT and the use of health IT to enhance safety This council should operate within an existing voluntary consensus standards organization

The Plan does not call for the creation of a Council but ONC plans to establish an ONC Safety Program to coordinate and implement this Plan The function of this program is to bull Coordinate the implementation of the Health IT Safety Plan by

o Ensuring all actors are fulfilling their responsibilities under the Plan

o Collaborating with actors to incorporate health IT and patient safety in their organization

o Providing funding if available and when necessary

bull Comprehensively analyze data from the different data entities which includes o Collecting and aggregating data among the different data entities o Identifying trends in patient safety and health IT o Providing feedback to developers and providers o Submitting policy recommendations to government agencies and Congress

bull Eliminate or significantly reduce inefficiencies across the programs by o Identifying any unnecessary overlap that occurs when implementing the Plan

(eg whether multiple agencies are investigating the same events) o Evaluating the outcomes and effectiveness of the Plan as it is implemented o Determining from the outcomes what actions are beneficial unnecessary or

insufficient (and whether additional actions are required

The ONC Safety Program will develop policies and procedures to establish an ad hoc steering committee that addresses major health IT safety issues

Recommendation 5

All health IT developers should be required to publicly register and list their products with the ONC initially beginning with EHRs certified for the meaningful use program

Registering and listing EHR developer products certified for Meaningful Use is already being performed by ONC The Plan will also incorporate additional health IT-related safety criteria for certification

Health IT Patient Safety Action amp Surveillance Plan for Public Comment 29



Recommendation 6

The Secretary of HHS should specify the quality and risk management process requirements that health IT developers must adopt with a particular focus on human factors safety culture and usability

As part of the 2014 Edition Standards and Certification Criteria final rule ONC adopted two safety-enhanced certification criteria This regulation included requirements for the application of user-centered design and quality management systems

ONC will fund health IT safety interventions in hospitals and physician practices to evaluate risk management implementation processes and interventions related to the safety of health IT

ONC will support research of approaches that would inform the processes necessary to mitigate risks and improve the quality and accuracy of patient matching

Recommendation 7

The Secretary of HHS should establish a mechanism for both developers and users to report health ITndashrelated deaths serious injuries or unsafe conditions

ONC will work with AHRQ PSOs and the FDA to collect and analyze reports of health ITndashrelated deaths serious injuries or unsafe conditions

Recommendation 7a

Reporting of health ITndashrelated adverse events should be mandatory for developers

ONC will engage developers and facilitate the development of a voluntary code of conduct that ensures vendors work with safety organizations to aggregate and analyze events and promote adverse event reporting among providers

ONC-ACBs will be encouraged to review documentation of complaints and provide de-identified reports to ONC

ONC will monitor health IT adverse event reports using the FDArsquos Manufacturer and User Facility Device Experience (MAUDE) database

30



Recommendation 7b

Reporting of health ITndashrelated adverse events by users should be voluntary confidential and nonpunitive

AHRQ will encourage PSOs to help providers incorporate AHRQ Common Formats when reporting health IT - related patient safety events to the Network of Patient Safety Databases (NPSD)

AHRQ is already developing the Quality amp Safety Review System (QSRS) to facilitate retrospective surveillance of harm from all causes health IT safety events AHRQ will also investigate development of a health IT profile for hospitals with QSRS that can detect differences in adverse event rates at hospitals correlated with their level of health IT implementation

AHRQ will also issue guidance on how to more effectively involve health IT expertise including from EHR developers in reporting to PSOs and in analysis and correction of problems

ONC will coordinate with state governments to encourage the reporting of health IT-related adverse events and to encourage providers to use AHRQ Common Formats when reporting

31



Recommendation 7c

Efforts to encourage reporting should be developed such as removing the perceptual cultural contractual legal and logistical barriers to reporting

The Plan also calls for AHRQ to encourage PSOs to help providers use AHRQ Common Formats when reporting patient safety events The most recent version of the Formats includes a ldquoDevice with Health ITrdquo format that allows collection of standardized information about IT-related adverse events as well as all events where health IT may be a contributing factor

To help inform ONCrsquos work with standards and certification criteria related to patient safety AHRQ plans to test extraction of data elements identical and related to AHRQrsquos Common Formats from multiple established EHR implementations and exportation of this data to hospital incident reporting systems

ONC recently funded a Purple Challenge Award to address the need for development of tools and interfaces that decrease reporting burden and improve workflow efficiency that surround adverse event reporting to hospital incident reporting systems and PSOs

ONCrsquos regulations establish standards and certification criteria for certified EHR technology and ONC intends to propose using certification criteria to ensure that where appropriate EHR technology is can be used to report safety events in AHRQrsquos Common Formats

Recommendation 8

The Secretary of HHS should recommend that Congress establish an independent federal entity for investigating patient safety deaths serious injuries or potentially unsafe conditions associated with health IT This entity should also monitor and analyze data and publicly report results of these activities

Currently the Health IT Safety Plan does not include the establishment of an independent federal entity However the plan incorporates many of the functions described in IOMrsquos recommendation 8 into existing patient safety efforts across government programs and the private sector mdash including health care providers technology companies and health care safety oversight bodies

32



Recommendation 9a

The Secretary of HHS should monitor and publicly report on the progress of health IT safety annually beginning in 2012 If progress toward safety and reliability is not sufficient as determined by the Secretary the Secretary should direct FDA to exercise all available authorities to regulate EHRs health information exchanges and PHRs

This Health IT Patient Safety Plan serves as the HHS report on the progress of health IT safety for 2012

Recommendation 9b

The Secretary should immediately direct FDA to begin developing the necessary framework for regulation Such a framework should be in place if and when the Secretary decides the state of health IT safety requires FDA regulation as stipulated in Recommendation 9a above

Under the FDA Safety and Innovation Safety Act of 2012 the FDA with the collaboration of ONC and the Federal Communications Commission (FCC) will release a report proposing a strategy and recommendations for an appropriate risk-based regulatory framework for health IT which promotes safety and innovation

Recommendation 10

HHS in collaboration with other research groups should support cross-disciplinary research toward the use of health IT as part of a learning health care system Products of this research should be used to inform the design testing and use of health IT Specific areas of research include

a User-centered design and human factors applied to rhealth IT

b Safe implementation and use of health IT by all users

c Sociotechnical systems associated with health IT and

d Impact of policy decisions on health IT use in clinical practice

ONC AHRQ and NLM are each supporting development and piloting of different interventions and tools aimed at improving health IT safety and evaluating the effectiveness of those tools in hospitals and provider practices (eg Hazard Manager Promoting Patient Safety through Effective Health IT Risk Management SAFER Guides Workflow Assessment for Health IT Toolkit Guide to Reducing Unintended Consequences of Electronic Health Records Implementation Toolsets for E-Prescribing ndash see also Appendix A) AHRQ already has a portfolio of useful tools and eports for addressing the potential safety issues that arise when implementing and

using EHRs

33


Appendix B Research and Development of Tools Measures and PoliciesDate ResearchDevelopment Projects

2011

IOM study (92010-112011) IOM was commissioned by ONC and published the report ldquoHealth IT and Patient Safety o

Building Safer Systems for Better Carerdquo

2012

Patient Safety Reporting Challenge Award

o

ONC funded a Purple Challenge Award to encourage development of tools and interfaces othat decrease reporting burden

The first winner of this challenge was KBCoreSM of Houston

2012

Usability Development

bull

bull NIST developed tools for usability testing of certified EHR technology bull SHARP- C is developing usability testing tools using NIST protocols ONC and NIST will continue to build upon this work and ONC will use it to strengthen safety-

enhanced certification criteria bull Usability Workshop

2012

Hazard Manager

bull AHRQ has developed the Hazard Manager a software tool that will alert users to potential health IT-related patient safety events

2012

Workflow Assessment for Health IT Toolkit

bull AHRQ has developed the Workflow Assessment for Health IT Toolkit which helps small and medium-sized outpatient practices better assess their workflows and determine when and how health IT may be used

2012

Guide to Reducing Unintended Consequences of Electronic Health Records

bull AHRQ has developed the Guide to Reducing Unintended Consequences of Electronic Health Records which helps anticipate avoid and troubleshoot problems associated with EHR

2012

Implementation Toolsets for E-Prescribing

bull AHRQ has developed the Implementation Toolsets for E-Prescribing a guide for preparing for and launching an e-prescribing system

2012

Designing Consumer Health IT A Guide for Developers and Systems Designers

s

bull AHRQrsquos Health IT Portfolio has published ldquoDesigning Consumer Health IT A Guide for Developers and Systems Designersrdquo which presents suggested recommendations for designers and developers of consumer health IT products to incorporate safe design The guide iavailable at httphealthitahrqgovdevelopmentmethodsguide

34


Date ResearchDevelopment Projects 20

1335

Professional Forums

bull Workgroups or common interest groups should be established at professional forums such as HIMSS AMIA AMA and other medical professional associations

2013

35 SAFER Guides (92013)

bull ONC has contracted to develop health IT safety guides such as SAFER Guides

2013

35

bull ONC has contracted with RAND to engage hospital and ambulatory providers to implement health IT risk management tools

Promoting Patient Safety Through Effective Health IT Risk Management Contract

2014

36

bull FDA in collaboration with ONC and FCC will publish a report on strategy and recommendations for an appropriate risk-based regulatory framework for health IT which promotes safety and innovation

Report on appropriate risk-based regulatory framework for health IT

35 2013 action items reflect planned activities 36 2014 action items reflect planned activities

35


Appendix C Timeline of the Health IT Patient Safety Action and Surveillance Plan

Date ActionsPrograms

2010

CMS Meaningful Use (Stage 1) and ONC standards amp Certification (72010)

bull CMSrsquo Incentive Program requires use of features that can improve patient safety such as CPOEs o

CDSs and o

Maintaining lists of patient medications allergies and problems o

2011

Certified HIT Product List (CHPL)

bull Established by ONC CHPL provides the authoritative comprehensive listing of Complete EHRs and EHR Modules that have been certified by ONC-Authorized ONC-ACBs

2012

Medicare Patient Safety Monitoring System (MPSMS)

bull To compare the differences in quality and safety MPSMS abstractors will identify which patient records in the sample are from EHRs paper records and mixed records

2012


oo

bull Increased the required use of EHRs (as compared to Meaningful Use (Stage 1)) bull ONC adopted two safety-enhanced certification criteria

Publicly identify a method of ensuring user-centered design and Publicly identify an approach to quality management system

13013

2 3

7

ONC-ACB Surveillance

o

o

bull ONC will incorporate health IT and patient safety into ONC-ACB surveillance and certification of EHRs

bull ONC will provide guidance to ONC-ACBs regarding o Developers keeping a record of complaints

Making complaint records available to the certification body upon request o Taking appropriate action with respect to complaints and deficiencies found and Documenting actions taken

2013

37

Manufacturer and User Facility Device Experience (MAUDE)

bull ONC will monitor the MAUDE database for health IT ndash related adverse event reports

2013

37

CMS Surveys and Corrective actions

bull Align CMS health and safety standards with the safety of health IT and train surveyors bull ONC will work with CMS state surveyors and accreditation organizations with CMS-approved

programs so that these entities can recognize and investigate health IT ndash related adverse events bull CMS can require corrective actions of health IT ndash related patient safety issues

37 2013 action items reflect planned activities

36


Date ActionsPrograms 20

1338

Collecting aggregating and analyzing reports from AHRQ

bull AHRQ will issue guidance on how to more effectively involve health IT expertise including from EHR developers in reporting to PSOs and in analysis and correction of problems

bull PSOs and AHRQ should incorporate health IT and patient safety when o Facilitating reporting of patient safety events o Investigating patient safety events o Working with providers to mitigate patient safety hazards

o Aggregating and analyzing reports to identify trends in health IT ndash related patient safety events

bull HHS will publish a report based on the findings from the aggregation and analysis of these reports

2013

38

Increase Transparency and the Free Flow of Information (ONC and Developers)

bull ONC will engage health IT developers to facilitate the development of a voluntary code of conduct that o Embraces shared responsibility o Supports and makes it clear that users can engage in the full range of adverse event

reporting

2013

38

Encourage Medical Education and Training of Health IT and Patient Safety

bull ONC will work with the following types of organizations to foster a culture of safety and the dissemination of best-in-class tools (eg SAFER Guides) and strategies o Accrediting bodies o Patient safety organizations o Liability insurers o Educational organizations and o Professional associations

2013

38

Establish the ONC Safety Program

bull ONC will o Coordinate the implementation of the Health IT Safety Plan o Comprehensively analyze data from the data streams o Ensure that there are no redundancies or inefficiencies across the programs


37



1339

Incorporation of health IT and patient safety reporting by State Governments

bull CMS will work with states to look for health IT ndashrelated safety issues when conducting Surveys on CMSrsquos behalf

bull ONC will encourage states to consider health IT when collecting aggregating and analyzing patient safety data produced by statesrsquo existing reporting requirements

2013

39

Develop Safety measures and targets

bull ONC will lead a public-private process to identify health IT safety priority areas within that larger context general patient safety and create related measures and targets for reduction of health IT ndash related adverse events

2013

39

AHRQrsquos QSRS

bull To increase surveillance AHRQ will develop the Quality amp Safety Review System (QSRS) that incorporates the AHRQ Common Formats

2013

39

CMS Meaningful Use (Stage 3) and ONC standards amp Certification

bull Will propose increasing the required use of EHRs (as compared to Meaningful Use [stage 2])

bull ONC and CMS will continue to use rulemakings to enhance patient safety bull ONC intends to use certification criteria to ensure that EHR technology is used to report

safety events bull HIT Policy Committee is seeking comments on whether there should be a new Meaningful

Use requirement for providers to conduct a health IT safety risk assessment


38

Appendix D ONC Program


Health Information Technology Patient Safety Action amp Surveillance Plan

Table of Contents

Introduction























Appendices


Appendix B Research and Development of Tools Measures and Policies



ltlt13 ASCII85EncodePages false13 AllowPSXObjects false13 AllowTransparency false13 AlwaysEmbed [13 true13 ]13 AntiAliasColorImages false13 AntiAliasGrayImages false13 AntiAliasMonoImages false13 AutoFilterColorImages true13 AutoFilterGrayImages true13 AutoPositionEPSFiles true13 AutoRotatePages All13 Binding Left13 CalCMYKProfile (US Web Coated 050SWOP051 v2)13 CalGrayProfile (Dot Gain 20)13 CalRGBProfile (sRGB IEC61966-21)13 CannotEmbedFontPolicy Warning13 CheckCompliance [13 None13 ]13 ColorACSImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 ColorConversionStrategy LeaveColorUnchanged13 ColorImageAutoFilterStrategy JPEG13 ColorImageDepth -113 ColorImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 ColorImageDownsampleThreshold 15000013 ColorImageDownsampleType Bicubic13 ColorImageFilter DCTEncode13 ColorImageMinDownsampleDepth 113 ColorImageMinResolution 30013 ColorImageMinResolutionPolicy OK13 ColorImageResolution 30013 ColorSettingsFile ()13 CompatibilityLevel 1413 CompressObjects Tags13 CompressPages true13 ConvertImagesToIndexed true13 CreateJDFFile false13 CreateJobTicket false13 CropColorImages false13 CropGrayImages false13 CropMonoImages false13 DSCReportingLevel 013 DefaultRenderingIntent Default13 Description ltlt13 ARA 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 BGR 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 CHS ltFEFF4f7f75288fd94e9b8bbe5b9a521b5efa7684002000500044004600206587686353ef901a8fc7684c976262535370673a548c002000700072006f006f00660065007200208fdb884c9ad88d2891cf62535370300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c676562535f00521b5efa768400200050004400460020658768633002gt13 CHT ltFEFF4f7f752890194e9b8a2d7f6e5efa7acb7684002000410064006f006200650020005000440046002065874ef653ef5728684c9762537088686a5f548c002000700072006f006f00660065007200204e0a73725f979ad854c18cea7684521753706548679c300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c4f86958b555f5df25efa7acb76840020005000440046002065874ef63002gt13 CZE 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 DAN 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 DEU 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 ENU (Use these settings to create Adobe PDF documents for quality printing on desktop printers and proofers Created PDF documents can be opened with Acrobat and Adobe Reader 50 and later)13 ESP ltFEFF005500740069006c0069006300650020006500730074006100200063006f006e0066006900670075007200610063006900f3006e0020007000610072006100200063007200650061007200200064006f00630075006d0065006e0074006f0073002000640065002000410064006f0062006500200050004400460020007000610072006100200063006f006e00730065006700750069007200200069006d0070007200650073006900f3006e002000640065002000630061006c006900640061006400200065006e00200069006d0070007200650073006f0072006100730020006400650020006500730063007200690074006f00720069006f00200079002000680065007200720061006d00690065006e00740061007300200064006500200063006f00720072006500630063006900f3006e002e002000530065002000700075006500640065006e00200061006200720069007200200064006f00630075006d0065006e0074006f00730020005000440046002000630072006500610064006f007300200063006f006e0020004100630072006f006200610074002c002000410064006f00620065002000520065006100640065007200200035002e003000200079002000760065007200730069006f006e0065007300200070006f00730074006500720069006f007200650073002egt13 ETI 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 FRA 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 GRE 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 HEB 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 HRV ltFEFF005a00610020007300740076006100720061006e006a0065002000410064006f00620065002000500044004600200064006f006b0075006d0065006e0061007400610020007a00610020006b00760061006c00690074006500740061006e0020006900730070006900730020006e006100200070006900730061010d0069006d006100200069006c0069002000700072006f006f006600650072002000750072006501110061006a0069006d0061002e00200020005300740076006f00720065006e0069002000500044004600200064006f006b0075006d0065006e007400690020006d006f006700750020007300650020006f00740076006f00720069007400690020004100630072006f00620061007400200069002000410064006f00620065002000520065006100640065007200200035002e0030002000690020006b00610073006e0069006a0069006d0020007600650072007a0069006a0061006d0061002egt13 HUN ltFEFF004d0069006e0151007300e9006700690020006e0079006f006d00610074006f006b0020006b00e90073007a00ed007400e9007300e900680065007a002000610073007a00740061006c00690020006e0079006f006d00740061007400f3006b006f006e002000e9007300200070007200f300620061006e0079006f006d00f3006b006f006e00200065007a0065006b006b0065006c0020006100200062006500e1006c006c00ed007400e10073006f006b006b0061006c002c00200068006f007a007a006f006e0020006c00e9007400720065002000410064006f00620065002000500044004600200064006f006b0075006d0065006e00740075006d006f006b00610074002e0020002000410020006c00e90074007200650068006f007a006f00740074002000500044004600200064006f006b0075006d0065006e00740075006d006f006b00200061007a0020004100630072006f006200610074002c00200061007a002000410064006f00620065002000520065006100640065007200200035002e0030002000e9007300200061007a002000610074007400f3006c0020006b00e9007301510062006200690020007600650072007a006900f3006b006b0061006c00200020006e00790069007400680061007400f3006b0020006d00650067002egt13 ITA 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 JPN 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 KOR ltFEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020b370c2a4d06cd0d10020d504b9b0d1300020bc0f0020ad50c815ae30c5d0c11c0020ace0d488c9c8b85c0020c778c1c4d560002000410064006f0062006500200050004400460020bb38c11cb97c0020c791c131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c00200050004400460020bb38c11cb2940020004100630072006f0062006100740020bc0f002000410064006f00620065002000520065006100640065007200200035002e00300020c774c0c1c5d0c11c0020c5f40020c2180020c788c2b5b2c8b2e4002egt13 LTH 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 LVI 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 NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken voor kwaliteitsafdrukken op desktopprinters en proofers De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 50 en hoger)13 NOR 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 POL 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 PTB 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 RUM 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 RUS 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 SKY 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 SLV 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 SUO 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 SVE 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 TUR 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 UKR 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 gtgt13 DetectBlends true13 DetectCurves 013 DoThumbnails false13 DownsampleColorImages true13 DownsampleGrayImages true13 DownsampleMonoImages true13 EmbedAllFonts true13 EmbedJobOptions true13 EmbedOpenType false13 EmitDSCWarnings false13 EncodeColorImages true13 EncodeGrayImages true13 EncodeMonoImages true13 EndPage -113 ExportLayers ExportAllLayers13 GrayACSImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 GrayImageAutoFilterStrategy JPEG13 GrayImageDepth -113 GrayImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 GrayImageDownsampleThreshold 15000013 GrayImageDownsampleType Bicubic13 GrayImageFilter DCTEncode13 GrayImageMinDownsampleDepth 213 GrayImageMinResolution 30013 GrayImageMinResolutionPolicy OK13 GrayImageResolution 30013 ImageMemory 104857613 JPEG2000ColorACSImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 JPEG2000ColorImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 JPEG2000GrayACSImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 JPEG2000GrayImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 LockDistillerParams false13 MaxSubsetPct 10013 MonoImageDepth -113 MonoImageDict ltlt13 K -113 gtgt13 MonoImageDownsampleThreshold 15000013 MonoImageDownsampleType Bicubic13 MonoImageFilter CCITTFaxEncode13 MonoImageMinResolution 120013 MonoImageMinResolutionPolicy OK13 MonoImageResolution 120013 Namespace [13 (Adobe)13 (Common)13 (10)13 ]13 NeverEmbed [13 true13 ]13 OPM 113 Optimize true13 OtherNamespaces [13 ltlt13 AsReaderSpreads false13 CropImagesToFrames true13 ErrorControl WarnAndContinue13 FlattenerIgnoreSpreadOverrides false13 IncludeGuidesGrids false13 IncludeNonPrinting false13 IncludeSlug false13 Namespace [13 (Adobe)13 (InDesign)13 (40)13 ]13 OmitPlacedBitmaps false13 OmitPlacedEPS false13 OmitPlacedPDF false13 SimulateOverprint Legacy13 gtgt13 ltlt13 AddBleedMarks false13 AddColorBars false13 AddCropMarks false13 AddPageInfo false13 AddRegMarks false13 BleedOffset [13 013 013 013 013 ]13 ConvertColors NoConversion13 DestinationProfileName ()13 DestinationProfileSelector NA13 Downsample16BitImages true13 FlattenerPreset ltlt13 PresetSelector MediumResolution13 gtgt13 FormElements false13 GenerateStructure true13 IncludeBookmarks false13 IncludeHyperlinks false13 IncludeInteractive false13 IncludeLayers false13 IncludeProfiles true13 MarksOffset 613 MarksWeight 02500013 MultimediaHandling UseObjectSettings13 Namespace [13 (Adobe)13 (CreativeSuite)13 (20)13 ]13 PDFXOutputIntentProfileSelector NA13 PageMarksFile RomanDefault13 PreserveEditing true13 UntaggedCMYKHandling LeaveUntagged13 UntaggedRGBHandling LeaveUntagged13 UseDocumentBleed false13 gtgt13 ltlt13 AllowImageBreaks true13 AllowTableBreaks true13 ExpandPage false13 HonorBaseURL true13 HonorRolloverEffect false13 IgnoreHTMLPageBreaks false13 IncludeHeaderFooter false13 MarginOffset [13 013 013 013 013 ]13 MetadataAuthor ()13 MetadataKeywords ()13 MetadataSubject ()13 MetadataTitle ()13 MetricPageSize [13 013 013 ]13 MetricUnit inch13 MobileCompatible 013 Namespace [13 (Adobe)13 (GoLive)13 (80)13 ]13 OpenZoomToHTMLFontSize false13 PageOrientation Portrait13 RemoveBackground false13 ShrinkContent true13 TreatColorsAs MainMonitorColors13 UseEmbeddedProfiles false13 UseHTMLTitleAsMetadata true13 gtgt13 ]13 PDFX1aCheck false13 PDFX3Check false13 PDFXBleedBoxToTrimBoxOffset [13 013 013 013 013 ]13 PDFXCompliantPDFOnly false13 PDFXNoTrimBoxError true13 PDFXOutputCondition ()13 PDFXOutputConditionIdentifier ()13 PDFXOutputIntentProfile ()13 PDFXRegistryName ()13 PDFXSetBleedBoxToMediaBox true13 PDFXTrapped False13 PDFXTrimBoxToMediaBoxOffset [13 013 013 013 013 ]13 ParseDSCComments true13 ParseDSCCommentsForDocInfo true13 ParseICCProfilesInComments true13 PassThroughJPEGImages true13 PreserveCopyPage true13 PreserveDICMYKValues true13 PreserveEPSInfo true13 PreserveFlatness false13 PreserveHalftoneInfo false13 PreserveOPIComments false13 PreserveOverprintSettings true13 Start13 SubsetFonts true13 TransferFunctionInfo Apply13 UCRandBGInfo Preserve13 UsePrologue false13 sRGBProfile (sRGB IEC61966-21)13gtgt setdistillerparams13ltlt13 HWResolution [2400 2400]13 PageSize [612000 792000]13gtgt setpagedevice13


Table of Contents

Introduction 3

Health IT Patient Safety Goal 5

Health IT Patient Safety Objectives 7

Health IT Patient Safety Strategies and Actions 9

Appendix A Crosswalk of Health IT Patient Safety Plan amp IOMrsquos 2011 Recommendations from Health IT and Patient Safety Building Safer Systems for Better Care 23

Appendix B Research and Development of Tools Measures and Policies 34

Appendix C Timeline of the Health IT Patient Safety Action and Surveillance Plan 36

Appendix D ONC Program 39

2



Introduction







IOM (Institute of Medicine) 2012 Health IT and Patient Safety Building Safer Systems for Better Care Washington DC The National Academies Press Page 31

3

1









IOM 2012 Health IT and Patient Safety Building Safer Systems for Better Care Washington DC The National Academies Press

4

2















5

4















IOM Report (P 125)










7








8




Learn








9


9










10












11







12












13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices





ltlt13 ASCII85EncodePages false13 AllowPSXObjects false13 AllowTransparency false13 AlwaysEmbed [13 true13 ]13 AntiAliasColorImages false13 AntiAliasGrayImages false13 AntiAliasMonoImages false13 AutoFilterColorImages true13 AutoFilterGrayImages true13 AutoPositionEPSFiles true13 AutoRotatePages All13 Binding Left13 CalCMYKProfile (US Web Coated 050SWOP051 v2)13 CalGrayProfile (Dot Gain 20)13 CalRGBProfile (sRGB IEC61966-21)13 CannotEmbedFontPolicy Warning13 CheckCompliance [13 None13 ]13 ColorACSImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 ColorConversionStrategy LeaveColorUnchanged13 ColorImageAutoFilterStrategy JPEG13 ColorImageDepth -113 ColorImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 ColorImageDownsampleThreshold 15000013 ColorImageDownsampleType Bicubic13 ColorImageFilter DCTEncode13 ColorImageMinDownsampleDepth 113 ColorImageMinResolution 30013 ColorImageMinResolutionPolicy OK13 ColorImageResolution 30013 ColorSettingsFile ()13 CompatibilityLevel 1413 CompressObjects Tags13 CompressPages true13 ConvertImagesToIndexed true13 CreateJDFFile false13 CreateJobTicket false13 CropColorImages false13 CropGrayImages false13 CropMonoImages false13 DSCReportingLevel 013 DefaultRenderingIntent Default13 Description ltlt13 ARA 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 BGR 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 CHS ltFEFF4f7f75288fd94e9b8bbe5b9a521b5efa7684002000500044004600206587686353ef901a8fc7684c976262535370673a548c002000700072006f006f00660065007200208fdb884c9ad88d2891cf62535370300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c676562535f00521b5efa768400200050004400460020658768633002gt13 CHT ltFEFF4f7f752890194e9b8a2d7f6e5efa7acb7684002000410064006f006200650020005000440046002065874ef653ef5728684c9762537088686a5f548c002000700072006f006f00660065007200204e0a73725f979ad854c18cea7684521753706548679c300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c4f86958b555f5df25efa7acb76840020005000440046002065874ef63002gt13 CZE ltFEFF005400610074006f0020006e006100730074006100760065006e00ed00200070006f0075017e0069006a007400650020006b0020007600790074007600e101590065006e00ed00200064006f006b0075006d0065006e0074016f002000410064006f006200650020005000440046002000700072006f0020006b00760061006c00690074006e00ed0020007400690073006b0020006e0061002000730074006f006c006e00ed006300680020007400690073006b00e10072006e00e100630068002000610020006e00e1007400690073006b006f007600fd006300680020007a0061015900ed007a0065006e00ed00630068002e002000200056007900740076006f01590065006e00e900200064006f006b0075006d0065006e007400790020005000440046002000620075006400650020006d006f017e006e00e90020006f007400650076015900ed007400200076002000700072006f006700720061006d0065006300680020004100630072006f00620061007400200061002000410064006f00620065002000520065006100640065007200200035002e0030002000610020006e006f0076011b006a016100ed00630068002egt13 DAN ltFEFF004200720075006700200069006e0064007300740069006c006c0069006e006700650072006e0065002000740069006c0020006100740020006f007000720065007400740065002000410064006f006200650020005000440046002d0064006f006b0075006d0065006e007400650072002000740069006c0020006b00760061006c00690074006500740073007500640073006b007200690076006e0069006e006700200065006c006c006500720020006b006f007200720065006b007400750072006c00e60073006e0069006e0067002e0020004400650020006f007000720065007400740065006400650020005000440046002d0064006f006b0075006d0065006e0074006500720020006b0061006e002000e50062006e00650073002000690020004100630072006f00620061007400200065006c006c006500720020004100630072006f006200610074002000520065006100640065007200200035002e00300020006f00670020006e0079006500720065002egt13 DEU 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 ENU (Use these settings to create Adobe PDF documents for quality printing on desktop printers and proofers Created PDF documents can be opened with Acrobat and Adobe Reader 50 and later)13 ESP ltFEFF005500740069006c0069006300650020006500730074006100200063006f006e0066006900670075007200610063006900f3006e0020007000610072006100200063007200650061007200200064006f00630075006d0065006e0074006f0073002000640065002000410064006f0062006500200050004400460020007000610072006100200063006f006e00730065006700750069007200200069006d0070007200650073006900f3006e002000640065002000630061006c006900640061006400200065006e00200069006d0070007200650073006f0072006100730020006400650020006500730063007200690074006f00720069006f00200079002000680065007200720061006d00690065006e00740061007300200064006500200063006f00720072006500630063006900f3006e002e002000530065002000700075006500640065006e00200061006200720069007200200064006f00630075006d0065006e0074006f00730020005000440046002000630072006500610064006f007300200063006f006e0020004100630072006f006200610074002c002000410064006f00620065002000520065006100640065007200200035002e003000200079002000760065007200730069006f006e0065007300200070006f00730074006500720069006f007200650073002egt13 ETI 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 FRA 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 GRE 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 HEB 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 HRV 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 HUN 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 ITA 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 JPN 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 KOR ltFEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020b370c2a4d06cd0d10020d504b9b0d1300020bc0f0020ad50c815ae30c5d0c11c0020ace0d488c9c8b85c0020c778c1c4d560002000410064006f0062006500200050004400460020bb38c11cb97c0020c791c131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c00200050004400460020bb38c11cb2940020004100630072006f0062006100740020bc0f002000410064006f00620065002000520065006100640065007200200035002e00300020c774c0c1c5d0c11c0020c5f40020c2180020c788c2b5b2c8b2e4002egt13 LTH 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 LVI 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 NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken voor kwaliteitsafdrukken op desktopprinters en proofers De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 50 en hoger)13 NOR ltFEFF004200720075006b00200064006900730073006500200069006e006e007300740069006c006c0069006e00670065006e0065002000740069006c002000e50020006f0070007000720065007400740065002000410064006f006200650020005000440046002d0064006f006b0075006d0065006e00740065007200200066006f00720020007500740073006b00720069006600740020006100760020006800f800790020006b00760061006c00690074006500740020007000e500200062006f007200640073006b0072006900760065007200200065006c006c00650072002000700072006f006f006600650072002e0020005000440046002d0064006f006b0075006d0065006e00740065006e00650020006b0061006e002000e50070006e00650073002000690020004100630072006f00620061007400200065006c006c00650072002000410064006f00620065002000520065006100640065007200200035002e003000200065006c006c00650072002000730065006e006500720065002egt13 POL 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 PTB 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 RUM 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 RUS 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 SKY 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 SLV 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 SUO 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 SVE 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 TUR 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 UKR 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 gtgt13 DetectBlends true13 DetectCurves 013 DoThumbnails false13 DownsampleColorImages true13 DownsampleGrayImages true13 DownsampleMonoImages true13 EmbedAllFonts true13 EmbedJobOptions true13 EmbedOpenType false13 EmitDSCWarnings false13 EncodeColorImages true13 EncodeGrayImages true13 EncodeMonoImages true13 EndPage -113 ExportLayers ExportAllLayers13 GrayACSImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 GrayImageAutoFilterStrategy JPEG13 GrayImageDepth -113 GrayImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 GrayImageDownsampleThreshold 15000013 GrayImageDownsampleType Bicubic13 GrayImageFilter DCTEncode13 GrayImageMinDownsampleDepth 213 GrayImageMinResolution 30013 GrayImageMinResolutionPolicy OK13 GrayImageResolution 30013 ImageMemory 104857613 JPEG2000ColorACSImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 JPEG2000ColorImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 JPEG2000GrayACSImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 JPEG2000GrayImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 LockDistillerParams false13 MaxSubsetPct 10013 MonoImageDepth -113 MonoImageDict ltlt13 K -113 gtgt13 MonoImageDownsampleThreshold 15000013 MonoImageDownsampleType Bicubic13 MonoImageFilter CCITTFaxEncode13 MonoImageMinResolution 120013 MonoImageMinResolutionPolicy OK13 MonoImageResolution 120013 Namespace [13 (Adobe)13 (Common)13 (10)13 ]13 NeverEmbed [13 true13 ]13 OPM 113 Optimize true13 OtherNamespaces [13 ltlt13 AsReaderSpreads false13 CropImagesToFrames true13 ErrorControl WarnAndContinue13 FlattenerIgnoreSpreadOverrides false13 IncludeGuidesGrids false13 IncludeNonPrinting false13 IncludeSlug false13 Namespace [13 (Adobe)13 (InDesign)13 (40)13 ]13 OmitPlacedBitmaps false13 OmitPlacedEPS false13 OmitPlacedPDF false13 SimulateOverprint Legacy13 gtgt13 ltlt13 AddBleedMarks false13 AddColorBars false13 AddCropMarks false13 AddPageInfo false13 AddRegMarks false13 BleedOffset [13 013 013 013 013 ]13 ConvertColors NoConversion13 DestinationProfileName ()13 DestinationProfileSelector NA13 Downsample16BitImages true13 FlattenerPreset ltlt13 PresetSelector MediumResolution13 gtgt13 FormElements false13 GenerateStructure true13 IncludeBookmarks false13 IncludeHyperlinks false13 IncludeInteractive false13 IncludeLayers false13 IncludeProfiles true13 MarksOffset 613 MarksWeight 02500013 MultimediaHandling UseObjectSettings13 Namespace [13 (Adobe)13 (CreativeSuite)13 (20)13 ]13 PDFXOutputIntentProfileSelector NA13 PageMarksFile RomanDefault13 PreserveEditing true13 UntaggedCMYKHandling LeaveUntagged13 UntaggedRGBHandling LeaveUntagged13 UseDocumentBleed false13 gtgt13 ltlt13 AllowImageBreaks true13 AllowTableBreaks true13 ExpandPage false13 HonorBaseURL true13 HonorRolloverEffect false13 IgnoreHTMLPageBreaks false13 IncludeHeaderFooter false13 MarginOffset [13 013 013 013 013 ]13 MetadataAuthor ()13 MetadataKeywords ()13 MetadataSubject ()13 MetadataTitle ()13 MetricPageSize [13 013 013 ]13 MetricUnit inch13 MobileCompatible 013 Namespace [13 (Adobe)13 (GoLive)13 (80)13 ]13 OpenZoomToHTMLFontSize false13 PageOrientation Portrait13 RemoveBackground false13 ShrinkContent true13 TreatColorsAs MainMonitorColors13 UseEmbeddedProfiles false13 UseHTMLTitleAsMetadata true13 gtgt13 ]13 PDFX1aCheck false13 PDFX3Check false13 PDFXBleedBoxToTrimBoxOffset [13 013 013 013 013 ]13 PDFXCompliantPDFOnly false13 PDFXNoTrimBoxError true13 PDFXOutputCondition ()13 PDFXOutputConditionIdentifier ()13 PDFXOutputIntentProfile ()13 PDFXRegistryName ()13 PDFXSetBleedBoxToMediaBox true13 PDFXTrapped False13 PDFXTrimBoxToMediaBoxOffset [13 013 013 013 013 ]13 ParseDSCComments true13 ParseDSCCommentsForDocInfo true13 ParseICCProfilesInComments true13 PassThroughJPEGImages true13 PreserveCopyPage true13 PreserveDICMYKValues true13 PreserveEPSInfo true13 PreserveFlatness false13 PreserveHalftoneInfo false13 PreserveOPIComments false13 PreserveOverprintSettings true13 StartPage 113 SubsetFonts true13 TransferFunctionInfo Apply13 UCRandBGInfo Preserve13 UsePrologue false13 sRGBProfile (sRGB IEC61966-21)13gtgt setdistillerparams13ltlt13 HWResolution [2400 2400]13 PageSize [612000 792000]13gtgt setpagedevice13



Introduction







IOM (Institute of Medicine) 2012 Health IT and Patient Safety Building Safer Systems for Better Care Washington DC The National Academies Press 1

3

1










4

2















5

4















IOM Report (P 125)










7








8




Learn








9


9










10












11







12












13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices















4

2















5

4















IOM Report (P 125)










7








8




Learn








9


9










10












11







12












13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices




















5

4















IOM Report (P 125)










7








8




Learn








9


9










10












11







12












13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices




















IOM Report (P 125)










7








8




Learn








9


9










10












11







12












13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices













8




Learn








9


9










10












11







12












13









14






15




Improve







16









National Academies Press 1 See Chapter 4 Opportunities to Build a Safer System for Health IT 26 77 Fed Reg 54189-54191 (September 4 2012) The final rule gives CEHRT developers the option during Stage 2 to



17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices









Learn








9


9










10












11







12












13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices







9










10












11







12












13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices

















11







12












13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices





ltlt13 ASCII85EncodePages false13 AllowPSXObjects false13 AllowTransparency false13 AlwaysEmbed [13 true13 ]13 AntiAliasColorImages false13 AntiAliasGrayImages false13 AntiAliasMonoImages false13 AutoFilterColorImages true13 AutoFilterGrayImages true13 AutoPositionEPSFiles true13 AutoRotatePages All13 Binding Left13 CalCMYKProfile (US Web Coated 050SWOP051 v2)13 CalGrayProfile (Dot Gain 20)13 CalRGBProfile (sRGB IEC61966-21)13 CannotEmbedFontPolicy Warning13 CheckCompliance [13 None13 ]13 ColorACSImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 ColorConversionStrategy LeaveColorUnchanged13 ColorImageAutoFilterStrategy JPEG13 ColorImageDepth -113 ColorImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 ColorImageDownsampleThreshold 15000013 ColorImageDownsampleType Bicubic13 ColorImageFilter DCTEncode13 ColorImageMinDownsampleDepth 113 ColorImageMinResolution 30013 ColorImageMinResolutionPolicy OK13 ColorImageResolution 30013 ColorSettingsFile ()13 CompatibilityLevel 1413 CompressObjects Tags13 CompressPages true13 ConvertImagesToIndexed true13 CreateJDFFile false13 CreateJobTicket false13 CropColorImages false13 CropGrayImages false13 CropMonoImages false13 DSCReportingLevel 013 DefaultRenderingIntent Default13 Description ltlt13 ARA 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 BGR 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 CHS ltFEFF4f7f75288fd94e9b8bbe5b9a521b5efa7684002000500044004600206587686353ef901a8fc7684c976262535370673a548c002000700072006f006f00660065007200208fdb884c9ad88d2891cf62535370300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c676562535f00521b5efa768400200050004400460020658768633002gt13 CHT ltFEFF4f7f752890194e9b8a2d7f6e5efa7acb7684002000410064006f006200650020005000440046002065874ef653ef5728684c9762537088686a5f548c002000700072006f006f00660065007200204e0a73725f979ad854c18cea7684521753706548679c300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c4f86958b555f5df25efa7acb76840020005000440046002065874ef63002gt13 CZE 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 DAN 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 DEU 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 ENU (Use these settings to create Adobe PDF documents for quality printing on desktop printers and proofers Created PDF documents can be opened with Acrobat and Adobe Reader 50 and later)13 ESP 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 ETI 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 FRA ltFEFF005500740069006c006900730065007a00200063006500730020006f007000740069006f006e00730020006100660069006e00200064006500200063007200e900650072002000640065007300200064006f00630075006d0065006e00740073002000410064006f00620065002000500044004600200070006f007500720020006400650073002000e90070007200650075007600650073002000650074002000640065007300200069006d007000720065007300730069006f006e00730020006400650020006800610075007400650020007100750061006c0069007400e90020007300750072002000640065007300200069006d007000720069006d0061006e0074006500730020006400650020006200750072006500610075002e0020004c0065007300200064006f00630075006d0065006e00740073002000500044004600200063007200e900e90073002000700065007500760065006e0074002000ea0074007200650020006f007500760065007200740073002000640061006e00730020004100630072006f006200610074002c002000610069006e00730069002000710075002700410064006f00620065002000520065006100640065007200200035002e0030002000650074002000760065007200730069006f006e007300200075006c007400e90072006900650075007200650073002egt13 GRE 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 HEB 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 HRV 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 HUN 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 ITA 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 JPN ltFEFF9ad854c18cea51fa529b7528002000410064006f0062006500200050004400460020658766f8306e4f5c6210306b4f7f75283057307e30593002537052376642306e753b8cea3092670059279650306b4fdd306430533068304c3067304d307e3059300230c730b930af30c830c330d730d730ea30f330bf3067306e53705237307e305f306f30d730eb30fc30d57528306b9069305730663044307e305930023053306e8a2d5b9a30674f5c62103055308c305f0020005000440046002030d530a130a430eb306f3001004100630072006f0062006100740020304a30883073002000410064006f00620065002000520065006100640065007200200035002e003000204ee5964d3067958b304f30533068304c3067304d307e30593002gt13 KOR ltFEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020b370c2a4d06cd0d10020d504b9b0d1300020bc0f0020ad50c815ae30c5d0c11c0020ace0d488c9c8b85c0020c778c1c4d560002000410064006f0062006500200050004400460020bb38c11cb97c0020c791c131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c00200050004400460020bb38c11cb2940020004100630072006f0062006100740020bc0f002000410064006f00620065002000520065006100640065007200200035002e00300020c774c0c1c5d0c11c0020c5f40020c2180020c788c2b5b2c8b2e4002egt13 LTH 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 LVI ltFEFF0049007a006d0061006e0074006f006a00690065007400200161006f00730020006900650073007400610074012b006a0075006d00750073002c0020006c0061006900200069007a0076006500690064006f00740075002000410064006f00620065002000500044004600200064006f006b0075006d0065006e0074007500730020006b00760061006c0069007400610074012b0076006100690020006400720075006b010101610061006e00610069002000610072002000670061006c006400610020007000720069006e00740065007200690065006d00200075006e0020007000610072006100750067006e006f00760069006c006b0075006d0075002000690065007300700069006500640113006a00690065006d002e00200049007a0076006500690064006f006a006900650074002000500044004600200064006f006b0075006d0065006e007400750073002c0020006b006f002000760061007200200061007400760113007200740020006100720020004100630072006f00620061007400200075006e002000410064006f00620065002000520065006100640065007200200035002e0030002c0020006b0101002000610072012b00200074006f0020006a00610075006e0101006b0101006d002000760065007200730069006a0101006d002egt13 NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken voor kwaliteitsafdrukken op desktopprinters en proofers De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 50 en hoger)13 NOR 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 POL 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 PTB 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 RUM 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 RUS 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 SKY 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 SLV 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 SUO 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 SVE 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 TUR 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 UKR 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 gtgt13 DetectBlends true13 DetectCurves 013 DoThumbnails false13 DownsampleColorImages true13 DownsampleGrayImages true13 DownsampleMonoImages true13 EmbedAllFonts true13 EmbedJobOptions true13 EmbedOpenType false13 EmitDSCWarnings false13 EncodeColorImages true13 EncodeGrayImages true13 EncodeMonoImages true13 EndPage -113 ExportLayers ExportAllLayers13 GrayACSImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 GrayImageAutoFilterStrategy JPEG13 GrayImageDepth -113 GrayImageDict ltlt13 HSamples [13 113 113 113 113 ]13 QFactor 01500013 VSamples [13 113 113 113 113 ]13 gtgt13 GrayImageDownsampleThreshold 15000013 GrayImageDownsampleType Bicubic13 GrayImageFilter DCTEncode13 GrayImageMinDownsampleDepth 213 GrayImageMinResolution 30013 GrayImageMinResolutionPolicy OK13 GrayImageResolution 30013 ImageMemory 104857613 JPEG2000ColorACSImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 JPEG2000ColorImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 JPEG2000GrayACSImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 JPEG2000GrayImageDict ltlt13 Quality 3013 TileHeight 25613 TileWidth 25613 gtgt13 LockDistillerParams false13 MaxSubsetPct 10013 MonoImageDepth -113 MonoImageDict ltlt13 K -113 gtgt13 MonoImageDownsampleThreshold 15000013 MonoImageDownsampleType Bicubic13 MonoImageFilter CCITTFaxEncode13 MonoImageMinResolution 120013 MonoImageMinResolutionPolicy OK13 MonoImageResolution 120013 Namespace [13 (Adobe)13 (Common)13 (10)13 ]13 NeverEmbed [13 true13 ]13 OPM 113 Optimize true13 OtherNamespaces [13 ltlt13 AsReaderSpreads false13 CropImagesToFrames true13 ErrorControl WarnAndContinue13 FlattenerIgnoreSpreadOverrides false13 IncludeGuidesGrids false13 IncludeNonPrinting false13 IncludeSlug false13 Namespace [13 (Adobe)13 (InDesign)13 (40)13 ]13 OmitPlacedBitmaps false13 OmitPlacedEPS false13 OmitPlacedPDF false13 SimulateOverprint Legacy13 gtgt13 ltlt13 AddBleedMarks false13 AddColorBars false13 AddCropMarks false13 AddPageInfo false13 AddRegMarks false13 BleedOffset [13 013 013 013 013 ]13 ConvertColors NoConversion13 DestinationProfileName ()13 DestinationProfileSelector NA13 Downsample16BitImages true13 FlattenerPreset ltlt13 PresetSelector MediumResolution13 gtgt13 FormElements false13 GenerateStructure true13 IncludeBookmarks false13 IncludeHyperlinks false13 IncludeInteractive false13 IncludeLayers false13 IncludeProfiles true13 MarksOffset 613 MarksWeight 02500013 MultimediaHandling UseObjectSettings13 Namespace [13 (Adobe)13 (CreativeSuite)13 (20)13 ]13 PDFXOutputIntentProfileSelector NA13 PageMarksFile RomanDefault13 PreserveEditing true13 UntaggedCMYKHandling LeaveUntagged13 UntaggedRGBHandling LeaveUntagged13 UseDocumentBleed false13 gtgt13 ltlt13 AllowImageBreaks true13 AllowTableBreaks true13 ExpandPage false13 HonorBaseURL true13 HonorRolloverEffect false13 IgnoreHTMLPageBreaks false13 IncludeHeaderFooter false13 MarginOffset [13 013 013 013 013 ]13 MetadataAuthor ()13 MetadataKeywords ()13 MetadataSubject ()13 MetadataTitle ()13 MetricPageSize [13 013 013 ]13 MetricUnit inch13 MobileCompatible 013 Namespace [13 (Adobe)13 (GoLive)13 (80)13 ]13 OpenZoomToHTMLFontSize false13 PageOrientation Portrait13 RemoveBackground false13 ShrinkContent true13 TreatColorsAs MainMonitorColors13 UseEmbeddedProfiles false13 UseHTMLTitleAsMetadata true13 gtgt13 ]13 PDFX1aCheck false13 PDFX3Check false13 PDFXBleedBoxToTrimBoxOffset [13 013 013 013 013 ]13 PDFXCompliantPDFOnly false13 PDFXNoTrimBoxError true13 PDFXOutputCondition ()13 PDFXOutputConditionIdentifier ()13 PDFXOutputIntentProfile ()13 PDFXRegistryName ()13 PDFXSetBleedBoxToMediaBox true13 PDFXTrapped False13 PDFXTrimBoxToMediaBoxOffset [13 013 013 013 013 ]13 ParseDSCComments true13 ParseDSCCommentsForDocInfo true13 ParseICCProfilesInComments true13 PassThroughJPEGImages true13 PreserveCopyPage true13 PreserveDICMYKValues true13 PreserveEPSInfo true13 PreserveFlatness false13 PreserveHalftoneInfo false13 PreserveOPIComments false13 PreserveOverprintSettings true13 Start3 SubsetFonts true13 TransferFunctionInfo Apply13 UCRandBGInfo Preserve13 UsePrologue false13 sRGBProfile (sRGB IEC61966-21)13gtgt setdistillerparams13ltlt13 HWResolution [2400 2400]13 PageSize [612000 792000]13gtgt setpagedevice13







12












13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices

















13









14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices














14






15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices











15




Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices









Improve







16












17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices

















17













18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices


















18










19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices















19




Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices









Lead







20
















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices





















21









22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices














22


Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices







Appendices



Recommendation 1



Recommendation 1a





23







24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices












24




Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices









Recommendation 1b




Recommendation 1c





25



Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








Recommendation 1d





Recommendation 1e





26



Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








Recommendation 2





27



Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








Recommendation 3





28


Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices







Recommendation 4











Recommendation 5






Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








Recommendation 6





Recommendation 7



Recommendation 7a





30



Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








Recommendation 7b






31



Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








Recommendation 7c






Recommendation 8



32



Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








Recommendation 9a



Recommendation 9b



Recommendation 10







using EHRs

33



2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








2011



2012


o



2012


bull



2012

Hazard Manager


2012



2012



2012



2012


s


34



1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








1335

Professional Forums


2013



2013

35



2014

36




35




2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices









2010



CDSs and o


2011



2012



2012


oo



13013

2 3

7


o

o




2013

37



2013

37





36



1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








1338






2013

38



reporting

2013

38



2013

38




37



1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices








1339




2013

39



2013

39

AHRQrsquos QSRS


2013

39







38




Table of Contents

Introduction























Appendices









Table of Contents

Introduction























Appendices






Health Information Technology Patient Safety Action ... information can be ... • Improve the...

Documents

Transcript of Health Information Technology Patient Safety Action ... information can be ... • Improve the...