September 2016

Oversight of HIT Safety a Top Priority
By Dava Stewart
For The Record
Vol. 28 No. 9 P. 30

Amid the rush to implement EHRs, the confusion of parsing all of the requirements necessary to claim meaningful use funds, and the difficulties involved in securing patient information to satisfy HIPAA regulations, it can be easy for health care organizations to lose sight of tying HIT systems to patient safety. However, Washington is offering resources to help make sure patient safety is a priority.

Recently, the Office of the National Coordinator for Health Information Technology (ONC) issued "Report on the Evidence on Health IT Safety and Interventions" and "Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT," part of an ongoing effort to provide tools and resources to organizations hoping to optimize the safe use of EHR systems.

Despite being an expert in patient safety and HIT, Hardeep Singh, MD, MPH, a researcher at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, admits to struggling to keep up with everything happening in the field. He says the scientific foundation surrounding how to best use HIT to keep patients safe is still evolving, adding that he welcomes the ONC's efforts. "It's nice to see national reports come out and synthesize the emerging research, concepts, models, tools, and strategies," Singh says.

Although there was nothing groundbreaking in the reports, experts such as Singh believe they will be beneficial. The updates, which key industry players may view as "state of the science," help disseminate the most recent advances. Nevertheless, competing priorities are often an issue, says Singh, who notes, "It's hard to get people's attention."

"Report on the Evidence on Health IT Safety and Interventions" focuses on issues such as research gaps, usability, and interoperability. "Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT" is a more hands-on tool that provides recommendations and solutions to possible safety issues.

In a blog post, Andrew Gettinger, MD, director of the Office of Clinical Quality and Safety, wrote, "Taken together, these reports highlight two key elements of health IT safety that inform our work across the board at ONC:

• Evidence continues to indicate that health IT safety is dependent not just on EHR systems themselves but on a complex interplay of factors, including an institution's leadership, culture, readiness, installation practices, training, and handling of upgrades. Improving safety requires attention to all of these areas.

• Efforts to enhance usability and interoperability across the health IT landscape also provide important opportunities to improve the safe use of health IT."

According to Singh, health care organizations must consider the following three domains when developing a framework for HIT safety:

• The technology itself must be safe and function properly.
• The use of that technology must be safe.
• The technology must proactively improve patient safety.

Real-Life Failures
A well-known and much-publicized computer glitch that affected patient safety occurred in 2006, when prescriptions for a smoking cessation aid were replaced with prescriptions for sildenafil, the generic form of Viagra. The bug, which originated in Scotland, is illustrative of the dangers posed by a software malfunction.

System-to-system interface problems are another potential HIT sore spot. Typically, organizations have multiple IT systems working together. For example, the EHR must communicate with the pharmacy as well as with various departments such as radiology to order and receive tests results. Singh says it's possible for a physician to order a long-acting form of morphine, but a glitch results in a fast-acting type coming across the interface instead.

Usability issues are often the source of many HIT mistakes. EHR user interface problems include graphs of diagnostic test results being displayed incorrectly, which can lead to errors in interpretation. However, Singh says EHR use is a complex sociotechnical process and usability extends beyond just interacting with a computer screen. He says health care organizations featuring a hybrid environment are particularly vulnerable. For example, when a digital system has been implemented for submitting laboratory test orders, but some staff members insist on still using paper, there is likely to be miscommunication, creating a greater possibility of an error occurring.

Dean Sittig, PhD, a professor at the school of biomedical informatics at the University of Texas Health Science Center in Houston, says physician alerts can lead to HIT system mishaps. For example, during flu season, it is likely that a large organization may send physicians between 200 and 300 daily alerts to offer patients a flu shot. When flu season is over, the alert will be switched off, but it may not be flipped back on the following November. "Nobody likes alerts, so nobody complains when they don't come back on," Sittig says, adding that the alerts provide a level of comfort. "It's a little akin to being a tightrope walker with a safety net. With a hidden error in the EHR, the safety net is gone but you don't know."

Software coding errors also can lead to HIT-related mishaps. Sittig recounts a situation in which a systems analyst attempting to edit a rule related to lead screening alerts for 2-year-olds entered the wrong logic. As a result, the alert was activated only when 2-year-olds were deemed to be smokers. Oddly enough, that did not eliminate all of the alerts—some 2-year-olds had been mistakenly documented as smokers.

What makes these error types even more concerning is that they are likely to go unnoticed. "The harm is very diffuse, and people are very tough, so often there is little or no harm immediately," Sittig says. Reports, such as those issued by the ONC, that recommend solutions to avoid errors can be effective risk management tools.

The Path to Safer, Better Care
While concerns exist about it being the source of potential errors, HIT can proactively improve patient safety and provide better care. In fact, Sittig says EHRs are themselves safety instruments, noting that the technology is often working behind the scenes much in the same way that most drivers don't give a second thought to antilock brakes.

Nevertheless, steps are being taken to continue to improve safety. For example, the National Quality Forum is taking a leading role in advocating the use of measurement and improvement of HIT-related patient safety. The ONC, too, is focused on safety, although Sittig says that wasn't the case when the office was first established. He adds that all parties in the care continuum must share in the responsibility to create a safe environment. This includes the federal government, EHR vendors, and clinicians. "The clinicians have a huge responsibility to get trained, follow directions, and use the tools as recommended," Sittig says.

Both Sittig and Singh say the development of a national HIT patient safety center that would operate similarly to the National Transportation Safety Board would be beneficial. Sittig says this would allow key industry players to learn from any system failures that may occur. "Even the American Medical Association recently started to support the development of such a center, but thus far Congress has not funded it," he notes.

With new threats such as ransomware emerging, patient safety is constantly at risk. The National Quality Forum, support from the ONC and The Joint Commission, and tools such as industry guidelines are all steps in the right direction toward improving safety. Still, there is much more that can and should be done in order to improve the safety and effectiveness of EHRs and ensure the highest quality of care for everyone.

— Dava Stewart is a freelance writer based in Tennessee.