WEBINAR WELCOME!
Raj RatwaniScientific director, National Center for Human Factors
in Healthcare, MedStar Institute for Innovation
Dr. Hardeep SinghChief of the health policy, quality
and informatics program, Michael E. DeBakey
VA Medical Center and Baylor College of Medicine
Joseph ConnModerator
Health information technology reporter Modern Healthcare
During today’s discussion, feel free to submit questions at any time by using the questions box.
A follow-up e-mail will be sent to all attendees with links to the presentation materials online.
Dr. Andy GettingerChief medical information officer and acting director,
Office of Clinical Quality and Safety, ONC
Panelists:
EHR SAFETY: Identifying and mitigating health IT-related risks
WEBINAR HOUSEKEEPING
NOW SPEAKING
Please use the questions box on your webinar dashboard to submit questions to our moderator
WEBINAREHR SAFETY: Identifying and mitigating health IT-related risks
Joseph ConnModerator
Health information technology reporter Modern Healthcare
NOW SPEAKING
Please use the questions box on your webinar dashboard to submit questions to our moderator
WEBINAREHR SAFETY: Identifying and mitigating health IT-related risks
Dr. Andy GettingerChief medical information officer
and acting director, Office of Clinical Quality and Safety,
ONC
ONC: EHR Usability
9/21/2015Office of the National Coordinator for
Health Information Technology0
• Focus on patient-centered
cognitive support for clinicians
• Short-term research that
addresses usability and
workflow
• Long-term research that can
remove key cognitive barriers
to HIT adoption and
meaningful use
9/21/2015Office of the National Coordinator for
Health Information Technology1
http://inspiredehrs.org
9/21/2015Office of the National Coordinator for
Health Information Technology2
• Nothing has been
approved at HHS or
Congress
• Seed money from HHS
• Public private
partnership
• Protected space for
work protected from
litigation
Safety Center is NOT
• A bricks and mortar
physical entity
• Federal entity collecting
data
9/21/2015Office of the National Coordinator for
Health Information Technology3
ONC Current Activity in Usability
9/21/2015Office of the National Coordinator for
Health Information Technology4
NOW SPEAKING
Please use the questions box on your webinar dashboard to submit questions to our moderator
WEBINAREHR SAFETY: Identifying and mitigating health IT-related risks
Dr. Hardeep SinghChief of the health policy, quality and
informatics program
Michael E. DeBakey VA Medical Center and Baylor College of Medicine
DEFINING AND MEASURING THE
INTERSECTION OF HEALTH IT
AND PATIENT SAFETY
HARDEEP SINGH, MD, MPHHOUSTON VETERANS AFFAIRS CENTER FOR INNOVATIONS IN
QUALITY, EFFECTIVENESS & SAFETY
MICHAEL E. DEBAKEY VA MEDICAL CENTER
BAYLOR COLLEGE OF MEDICINE
1
2
Safety Begins with Measurement
We cannot improve what we cannot
measure!
We cannot measure what we cannot
define!
3
8-dimensional Socio-Technical Model of Safe & Effective Health IT Use
4
Sittig Singh QSHC 2010
Health IT Safety Hierarchy – 3 Phases5
� Phase 1: Safe health IT:
� Events unique/specific to health IT
Sittig & Singh N Engl J Med. 2012 Nov 8;367(19):1854-60
6
Health IT Safety Hierarchy– 3 Phases7
� Phase 1: Safe health IT:
� Events unique/specific to health IT
� Phase 2: Using health IT safely:
� Unsafe or inappropriate use of technology
� Unsafe changes in the workflows that emerge from technology use
Sittig & Singh N Engl J Med. 2012 Nov 8;367(19):1854-60
9
Health IT Safety Hierarchy – 3 Phases10
� Phase 1: Safe health IT :
� Events unique/specific to EHRs
� Phase 2: Using health IT safely:
� Unsafe or inappropriate use of technology
� Unsafe changes in the workflows that emerge from technology use
� Phase 3: Using health IT to improve safety
� Leveraging health IT to identify unsafe care processes and potential patient safety concerns before harm
Sittig & Singh N Engl J Med. 2012 Nov 8;367(19):1854-60
Singh Sittig BMJ Qual Saf doi:10.1136/bmjqs-2015-004486
Which HIT-related Safety Concerns to Measure?
13
Type of HIT-related safety concern Examples
1. Instances in which HIT fails during use or is otherwise not working as designed.
Broken hardware or software “bugs”
2. Instances in which HIT is working as designed, but the design does not meet the user’s needs or expectations.
Usability issues
3. Instances in which HIT is well-designed and working correctly, but was not configured, implemented, or used in a way anticipated
or planned for by system designers and developers
Duplicate order alerts that fire on alternative PRN pain medications
Sittig Classen Singh J Am Med Inform Assoc. 2014 Oct 20
Which HIT-related Safety Concerns to Measure?
14
Type of HIT-related safety concern Examples
4. Instances in which HIT is working as designed, and was configured and used correctly, but interacts with external systems (e.g., via
hardware or software interfaces) so that
data is lost or incorrectly transmitted or
displayed.
Medication order for extended release morphine inadvertently changed to immediate release morphine by error in interface translation table
5. Instances in which specific safety features or functions were not implemented or not
available (i.e., HIT could have prevented a safety concern).
Hospitalized patient inadvertently receives 5 grams of acetaminophen in 24 hours because maximum daily dose alerting was not available
Sittig Classen Singh J Am Med Inform Assoc. 2014 Oct 20
Proactive Measurement
� ONC-sponsored “Safety Assurance Factors for EHR Resilience (SAFER) project”
� Proactive risk assessment and guidance
� “1st draft” of best practices and knowledge
� Self-assessment; not meant to be regulatory
� Focused on high-risk areas
� Nine guides—all freely available
Singh et al BMC Med Inf 2013
15
http://www.healthit.gov/safer
� Foundational Guides
� High Priority Practices
� Organizational Responsibilities
� Infrastructure Guides
� System Configuration
� System Interfaces
� Contingency Planning
� Clinical Process Guides
� Patient Identification
� Computerized Provider Order Entry with CDS
� Test Results Reporting and Follow-up
� Clinician Communication
SAFER: Safety Assurance Factors for EHR Resilience
Sittig, Singh, Ash. Am J Manag Care. 2014;20(5):418-423
16
http://www.healthit.gov/safer
SAFER Recommended Practices17
Take Home20
� Essential to have robust definitions & measurement approaches
� Certain risk areas are now well defined and amenable to local measurement for QI/safety purposes
� Measuring health IT-related safety needs to become an essential component of overall patient safety strategy
Thank you…21
Funding Agencies
� Department of Veterans Affairs
� Agency for Health Care Research & Quality
� National Institute of Health
� Office of National Coordinator (SAFER Guides)
� Multidisciplinary team at Houston-based VA Health Services Research Center of Innovation
Contact Information…
Hardeep Singh, MD, MPH
@HardeepSinghMD
NOW SPEAKING
WEBINAREHR SAFETY: Identifying and mitigating health IT-related risks
Please use the questions box on your webinar dashboard to submit questions to our moderator
Raj RatwaniScientific director
National Center for Human Factors in Healthcare,
MedStar Institute for Innovation
Health IT Usability, Clinician
Workflow, and Safety Hazard
Identification
Raj Ratwani, PhD
Scientific Director
National Center for Human Factors in Healthcare,
MedStar Health
Assistant Professor of Emergency Medicine,
Georgetown University
1: User Interface Design
Displays and Controls
Screen Design
Clicks & Drags
Colors & Navigation
The Two Bins of Usability
2: Cognitive Task Support
“Workflow Design”
Smart Data Visualization
Support Cognitive Work
Functionality
Photo credit to Bob Wears, MD, PhD
EHR Usability
• Many vendors are not employing rigorous User-
centered design processes
• Safety enhanced design reports demonstrate:
– Many vendors are not adhering to
requirements
– Testing standards are violated
• What is the frontline impact?
Ratwani, R.M., Benda, N., Hettinger, A.Z., & Fairbanks, R.J. (2015) Electronic Health Record Vendor Adherence to Usability
Certification Requirements and Testing Standards. Journal of the American Medical Association (JAMA) 314(10):1070-1071.
Ratwani, R.M., Fairbanks, R.J., Hettinger, A.Z. & Benda, N. (2015). Electronic Health Record Usability: Analysis of the User Centered
Design Processes of Eleven Electronic Health Record Vendors. Journal of the American Medical Informatics Association.
Frontline Impact
• How does use of a new EHR with CPOE impact physician performance in the ED?– Three study periods: pre, go-live, post
– 2 hour observation periods
– 14 EM physicians during each phase
• Observers record minute by minute allocation to different tasks– Computer, verbal communication, patient
time, paper
Benda, N., Meadors, MA, Hettinger, A.Z, and Ratwani, R.M. (in
press). Emergency Physician Task Switching Increases with the
Introduction of a Commercial EHR. Annals of Emergency Medicine
Task Allocation Time
Benda, N., Meadors, MA, Hettinger, A.Z, and Ratwani, R.M. (in
press). Emergency Physician Task Switching Increases with the
Introduction of a Commercial EHR. Annals of Emergency Medicine
Tasks Per Minute
Benda, N., Meadors, MA, Hettinger, A.Z, and Ratwani, R.M. (in
press). Emergency Physician Task Switching Increases with the
Introduction of a Commercial EHR. Annals of Emergency Medicine
Significant Increase in Task
Switching
• The cognitive cost of the EHR is increased
task switching:
– Increased stress and frustration
– Increase likelihood of error
• Users are forced to adapt their work
practices to the EHR
Benda, N., Meadors, MA, Hettinger, A.Z, and Ratwani, R.M. (in
press). Emergency Physician Task Switching Increases with the
Introduction of a Commercial EHR. Annals of Emergency Medicine
Strategies for Identifying Safety
Hazards
• Observation and analysis in highest risk
clinical environments
– Task tracking, visualization and analysis
• Leveraging event reporting systems and
help desk data
– Visualization and natural language processing
Fong, A. & Ratwani, R.M. (2015). An Evaluation of Patient
Safety Event Report Categories Using Unsupervised Topic
Modeling. Methods of Information in Medicine. 54 (3).
Task Tracker
Workflow Visual Analytics Tool
Data Analytics
• Identify health IT related safety events
from adverse event data
– Visualization and natural language processing
techniques
• Examining “help desk” data to identify
patterns and trends
WEBINAR
TODAY’S PANELISTS
EHR SAFETY: Identifying and mitigating health IT-related risks
During today’s discussion, feel free to submit questions at any time by using the questions box
Raj RatwaniScientific director, National Center for Human Factors
in Healthcare, MedStar Institute for Innovation
Dr. Hardeep SinghChief of the health policy,
quality and informatics program, Michael E. DeBakey
VA Medical Center and Baylor College of Medicine
Joseph ConnModerator
Health information technology reporter Modern Healthcare
Dr. Andy GettingerChief medical information officer and acting director,
Office of Clinical Quality and Safety, ONC
Expect a follow-up email within two weeks with links to presentation materials and information about how to offer feedback.
For more information about upcoming webinars, please visit ModernHealthcare.com/webinars
WEBINAR THANK YOU FOR ATTENDING
Thanks also to our panelists:
EHR SAFETY: Identifying and mitigating health IT-related risks
Raj RatwaniScientific director, National Center for Human Factors in Healthcare, MedStar Institute for Innovation
Dr. Hardeep SinghChief of the health policy, quality and informatics program, Michael E. DeBakey VA Medical Center and Baylor College of Medicine
Joseph ConnModeratorHealth information technology reporter Modern Healthcare
Dr. Andy GettingerChief medical information officer, acting director, Office of Clinical Quality and Safety, ONC
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