Lessons from Implementation of an EHR
Discussion Mary K. Goldstein, MD
Patient Safety and Automation
• “All technology introduces new errors, even when its sole purpose is to reduce errors.” • “Latent errors or system failures pose the greatest threat to safety in a complex system because they lead to operator errors.”
• Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a safer health system. Washington, D.C.: National Academy Press; 2000.
Benefits and Risks of Health IT: Benefits
• Information technology can reduce workload and increase productivity • Can result in fewer errors by automating tasks and monitoring actions
• Patient safety in guideline-based decision support for hypertension management: ATHENA DSS. Goldstein MK, et al Proc AMIA Symp. 2001;:214-8.
Benefits and Risks of Health IT: Risks
• New computerized systems can affect human problem solving in ways that contribute to accidents
– Data overload can result from a computerized system’s ability to collect and display data out of proportion to human ability to use it effectively
• the 54 displayed data elements probably contributed to the Apollo 13 mission near disaster.
– Automated actions that are transparent or unknown to the user (“automation surprises”) may lead to errors
• automation may have created the conditions for an airplane to fly into a mountain, when the cockpit automation switched flight modes without the pilot’s knowledge.
Example from CPOE in an ICU
• Observational qualitative study of introduction of required CPOE in an ICU
• C.H. Cheng, M.K. Goldstein, E. Geller, R.E. Levitt. The effects of CPOE on ICU workflow: an observational study. In: Proc of the 2003 AMIA Fall Symposium (Page 150-154), Washington, D.C.
Computer system workflow diverges from actual workflow
Computer system workflow
Actual workflow
Reconciliation
Coordination redundancy:
Entering and interpreting orders
In 97 interruptions of RN to MD, 25% were reminders
Testing IT Systems
• Explicit testing of new systems can reveal problems that can be addressed in system redesign
– without loss of the new core capabilities of the system.
• Example
– a bar code medical administration (BCMA) system, introduced for the purpose of reducing medication error, was found in practice to have important unintended consequences such as unobservable automated actions of the system that created new opportunities for error
• Emphasizes importance of subjecting new clinical informatics systems to a safety review before the system is fielded
– And monitoring the system in actual use after it has been fielded
Example of Monitoring During Use of System
• AHRQ Patient Safety online book • http://www.ahrq.gov/qual/advances/
– Post-fielding Surveillance of a Guideline-based Decision Support System (PDF File, 232 KB; Word® File, 218 KB) Albert S. Chan, Susana B. Martins, Robert W. Coleman, Hayden B. Bosworth, Eugene Z. Oddone, Michael G. Shlipak, Samson W. Tu, Mark A. Musen, Brian B. Hoffman, Mary K. Goldstein
Work location
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Supplies Supplies
Entrance
House Staff Lounge
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Pharmacy
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Conference Room
Radiology
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RN Break Rm
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MD Beds
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Interruptions Awareness Verbal heads-up Delivery delays
Legend: Computer Telephone ABG station Table Door Monitors
CPOE workflow should resemble actual workflow
Computer system workflow
Actual workflow
Reconciliation