Health IT Hazard Manager: Design & Demo (Text Version)

Slide Presentation from the AHRQ 2011 Annual Conference

On September 19, 2011, James Walker and Andrea Hassol made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (4.4 MB). Plugin Software Help.


Slide 1

Health IT Hazard Manager: Design and Demo

HIT Hazard Manager

HIT Hazard Manager: Design & Demo

James M. Walker, MD, FACP; Principle investigator, Geisinger Health Systems
Andrea Hassol, MSPH; Project Director, Abt Associates
September 19, 2011

Images of the Geisinger and Abt Associates logos at bottom of slide.

Slide 2

Hazard Control

Hazard Control

Hazard analysis is accident analysis before the accident happens.
Nancy Leveson

Slide 3

Health IT Hazard Manager version 1.0 Beta Test

HIT Hazard Manager version 1.0 Beta Test

  1. Background and Purpose.
  2. Hazard Manager Demo.
  3. Beta Test Sites and Procedures.
  4. Preliminary Findings.
  5. Next Steps.

Slide 4

Health IT Hazard Manager

Health IT Hazard Manager

Development and Alpha-Test: Geisinger Health System

Beta Test Web site Implementation: ECRI Patient Safety Organization; Abt Associates

Beta Test Evaluation: Abt Associates; Geisinger Health System

Slide 5

Contributions of Health IT Related Hazards

The Contribution of HIT-Related Hazards to Patient Harm

Image: A flowchart displaying contributions of HIT-related hazards to patient harm is shown.

Slide 6

Hazard Control

Hazard Control

Image: A flowchart displaying hazard control is shown.

Slide 7

Feeding Back Incident Reports Into Hazard Control

Feeding Back Incident Reports Into Hazard Control

Image: A flowchart displaying Feeding back incident reports into Hazard Control is shown.

Slide 8

Health It Hazard Manager: Levels of Access (Security)

Health IT Hazard Manager
Levels of Access (Security)

  1. Health Care Organization (HCO): can enter, view and manage its own hazards; view hazards entered by other HCOs using the same software product (deidentified as to HCO).
  2. Software Vendor: can view its customers hazards (deidentified as to HCO).
  3. Policymakers, Researchers, Regulators: can view all hazards (deidentified as to HCO and vendor).

Slide 9

Health IT Hazard Manager: Ontology of Hazards

Health IT Hazard Manager
Ontology of Hazards

  • Discovery: when, how and who discovered the hazard; stage of discovery.
  • Causation: usability, data quality, software design, hardware, clinical decision support, implementation, user factors, other organizational factors.
  • Impact: risk and impact of care process compromise; seriousness of patient harm.
  • Corrective Action: interim and definitive fix, urgency.

Slide 10

Health IT Hazard Manager

HIT Hazard Manager

Image: A screen shot of the log on screen of the HIT Hazard Manager Web site is shown.

Slide 11

Health IT Hazard Manager

HIT Hazard Manager (continued)

Image: A screen shot of the description page of the HIT Hazard Manager is shown.

Slide 12

Health IT Hazard Manager

HIT Hazard Manager (continued)

Image: A screen shot of the discovery page of the HIT Hazard Manager is shown.

Slide 13

Health IT Hazard Manager

HIT Hazard Manager (continued)

Image: A screen shot of the causation page of the HIT Hazard Manager is shown.

Slide 14

Health IT Hazard Manager

HIT Hazard Manager (continued)

Image: A screen shot of the second causation page of the HIT Hazard Manager is shown.

Slide 15

Health IT Hazard Manager

HIT Hazard Manager (continued)

Image: A screen shot of the impact page of the HIT Hazard Manager is shown.

Slide 16

Health IT Hazard Manager

HIT Hazard Manager (continued)

Image: A screen shot of the corrective action page of the HIT Hazard Manager is shown.

Slide 17

Clinical-Decision Support (Check all that apply)

Image: A screen shot of a bar chart entitled "Clinical-Decision Support (Check all that apply)":

Percent of Hazards with Specified AttributeAll HazardsMy Organization's
Hazards
Faulty Recommendation3/13 (23%)0/4 (0%)
Missing Recommendation1/13 (8%)0/4 (0%)
Clinical Content Inadequate1/13 (8%)0/4 (0%)
Decision-Engine Logic Inadequate1/13 (8%)0/4 (0%)
Inappropriate Level of Automation0/13 (0%)0/4 (0%)
Other (specify)1/13 (8%)0/4(0%)

Slide 18

Health It Hazard Manager: Beta Test-version 1.0

Health IT Hazard Manager
Beta Test—version 1.0

7 test sites: integrated delivery systems, large and small hospitals, urban and rural.

  • Usability.
  • Usefulness.
  • Ontology of hazard attributes.
  • Automated Reports.
  • Inter-rater reliability.

4 vendors

Slide 19

Beta Test Preliminary Findings

Beta Test Preliminary Findings

  • An individual's role determines what hazards they become aware of:
    • IT implementation teams learn about potential hazards during testing.
    • IT Production teams learn about hazards that may compromise care processes.
    • Patient Safety teams learn about care process compromises that reach patients (with or without harm).
  • Hospitals have separate IT issues and patient incident reporting systems:
    • Are not explicitly designed for hazard identification.
    • But can help teams identify hazards.

Slide 20

Beta Test Preliminary Findings  

Beta Test Preliminary Findings

  • Failures to control hazards are often labeled "User error". The Hazard Manager supports more hazard control and less "blame the user".
  • "Harm is often limited to physical injury. the Hazard Manager raises awareness about psychological, financial and reputational harm.
  • Each causation category includes an "other specify" option to elicit additional user insights; the ontology will evolve over time to capture additional attributes of HIT hazards.

Slide 21

 Project Schedule

Project Schedule

  • Beta Test data collection complete, October, 2011.
  • Data analysis, November—December 2011.
  • All sites project meeting, December 2011.
  • Final Report, May 2012.
  • Software revised, May 2012.

Slide 22

 Questions? Comments?

Questions? Comments?

For more information:
andrea_hassol@abtassoc.com.

Current as of March 2012
Internet Citation: Health IT Hazard Manager: Design & Demo (Text Version): Slide Presentation from the AHRQ 2011 Annual Conference. March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/walker-hassol/index.html