First Do No Harm: Ensuring the Safe and Effective Use of Health IT (Text Version)

Slide Presentation from the AHRQ 2009 Annual Conference

On September 14, 2009, Ross Koppel made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.0 MB). Plugin Software Help.

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First Do No Harm: Ensuring the Safe and Effective Use of Health IT AHRQ HIT Conference Sept, 2009

Ross Koppel, Ph.D.
Sociology Department, University of Pennsylvania & Center for Clinical Epidemiology & Biostatistics,
School of Medicine, University of Pennsylvania
rkoppel@sas.upenn.edu

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Matt's First Assignment

• Review relevant work

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JAMA, March 9, 2005

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

• Ross Koppel, PhD
• Joshua P. Metlay, MD, PhD
• Abigail Cohen, PhD
• Brian Abaluck, BS
• A. Russell Localio, JD, MPH, MS
• Stephen E. Kimmel, MD, MSCE
• Brian L. Strom, MD, MPH

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Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

• List of positives
• Noted 22 problems, e.g.:
  • Wrong: pt, med, dose, test-linked meds
  • Confused dose cancelling = doubling dose when want to reduce dose
  • Wrong dose guidance

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Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

• Ultimate Claim: CPOE good but not good enough
• Emperor not naked, but sometimes threadbare

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Methods

• Survey
• Shadowing
• Interviews with leaders
• Intensive interviews
• Many focus groups
• IT workers
• Much more

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Reaction

• Vendors
• New York Times
• Wall Street Journal
• Washington Post
• NPR
• Millions of web hits
• Within months, JBI devoted section of issue

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More Reaction

An image of David Brailer is shown.

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Next: About 25 Articles on HIT

An image of a stack of papers is shown.

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Harrison, Koppel & Bar-Lev (JAMIA, 2007) Interactive Sociotechnical Systems Analysis

An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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Also, Harrison, & Koppel, 2009) Interactive Sociotechnical Systems Analysis

An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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Harrison, Koppel & Bar-Lev (JAMIA, 2007) Interactive Sociotechnical Systems Analysis

An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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An image of the "Interactive Sociotechnical Systems Analysis" is shown.

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An image of the "Interactive Sociotechnical Systems Analysis" is shown

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Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety

• ROSS KOPPEL, PHD,
• TOSHA WETTERNECK, MD, MS,
• JOEL LEON TELLES, PHD,
• BEN-TZION KARSH, PHD

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Patient wrist barcode

An image of a doctor and patient is shown.

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On every medicine

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31 Causes of workarounds e.g.,

Unreadable medication-barcodes (crinkled, smudged, torn, missing, covered by another label)

Don't forget to scan label!

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Causes:

• Unreadable or missing patient-ID-wristbands (chewed, soaked, missing)
• Elderly, Children, Moving (unit or floor or nursing home)
• Failing batteries of handheld scanners or linked computers
• Difficult-to-read or navigate screens
• Alert beeps that sound like confirmation beeps
• Emergencies
• Pharmacies sending only partial doses
• About 20 others.

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Results 1: Fifteen identified workarounds (a) (Extra Copies)

• 1 example..Reproducing patients' wristband ID-barcodes, & affixing them to nursing station, computer cart, supply room, pt's room doorjamb, medication dispensing machine.

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Results 1: Fifteen identified workarounds (b)

• Continued.. RN clipboard, scanner itself, in nurses' pockets or on belt-rings, or worn as a group of bangles on nurse's sleeve.
• And 14 other workarounds

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JAMA March 25, 2009

An image of a news paper article titled "Health Care Information Technology Vendors' "Hold Harmless" Clause" is shown.

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Two Clauses in HIT Vendor Contracts

• Who is responsible for errors? Even if hidden and embedded in the Software? And even if you are following the manual?

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Who can you tell? The Non-Disclosure Clause

An image of a Safe is shown.

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Other Recent Publications of Note

• COMPARISON OF 7 NATION'S USE OF CPOE. Health Affairs
• WAYS OF MEASURING MEDICATION ERRORS USING HIT. JAMIA
• WEBINARS AND M&Ms ANALYSIS OF THE 80 HOUR RULE FOLLOW UP ON CPOE ANALYSIS OF MEANINGFUL USE.

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Matt's Questions

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1. Should the issue of EHR safety be built into the Initiatives supported in HITECH?

WEARS & LEVESON

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2. What should be the research agenda in this area?

• Focus on quality.
• But conventional methods limited.

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3. What roles should the government and private industry play? The JC?

1. I say..
2. Others say..
3. Industry and representatives want..

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The Government's Role

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4. How do we ensure that implementations of products are done in a way that ensures safety?

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5. In what ways are vendors and healthcare organizations interacting to ensure safe and effective use of EHRs?

If you build it well enough, they will want it

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6. Create a health IT usability lab. How funded? How to work it?

• Yes
• Funding: Gov't, Industry and Users
• Recognize it's limited to in vitro testing. Great idea, but only a start.

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No. 7 (condensed)

• The Health IT Extension Centers will help clinicians become meaningful users.
• How can we�incorporate�support to ensure safe and effective use of health IT into the�services that they provide?
• Who else should we help?

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Simple Answer:

Build better software:

• Training faster
• Less onerous
• Fewer battles with counter intuitive designs

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Thank you! Questions?

Ross Koppel, Ph.D.
Sociology Department, University of Pennsylvania &
Center for Clinical Epidemiology & Biostatistics,
School of Medicine, University of Pennsylvania
rkoppel@sas.upenn.edu