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Search results for "Information Professionals"

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Press Release/Announcement

AHRQ announces interest in research on health IT safety.

Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. March 9, 2016. Publication No.NOT-HS-16-009.

This announcement highlights AHRQ funding opportunities to support continued research regarding the safe use and implementation of health information technology systems with a focus on usability, user interaction, human factors engineering, system monitoring, and performance.

Audiovisual > Audiovisual Presentation

Health IT Webinar Series.

Office of the National Coordinator for Health Information Technology and RTI International. December 2014–September 2015.

Health information technology (IT) is seen as an important facilitator of transparency in health care, despite problems associated with these systems. This series of 10 webinars highlighted topics and research associated with the goal of improving the use of health IT, a national plan for a new health IT infrastructure and how it would be implemented.

Web Resource > Government Resource

Patient Centered Medical Home Resource Center: Quality and Safety.

Rockville, MD: Agency for Healthcare Research and Quality.

The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure that team-based, coordinated, system-oriented, and accessible care is provided to patients in their homes. This Web site offers resources to support the application of systems principles in PCMHs and engage primary care clinicians, practices, and patients in achieving safety goals.

Book/Report

Health Information Technology Leadership Panel: Final Report.

Falls Church, VA: The Lewin Group, Inc.; 2005.

Prepared by the Lewin Group for the Department of Health and Human Services, this 45-page report summarizes the argument for widespread adoption of information technology (IT) systems as a mechanism to improve health care quality. The panel highlights three key imperatives, which include making IT implementation a top priority, encouraging the federal government to leverage its position to drive adoption, and promoting collaboration in these efforts with private sector purchasers and organizations. The report offers several strategic recommendations and also provides background on health IT, the associated economics, and factors that affect and promote adoption.

Audiovisual > Audiovisual Presentation

A National Web Conference on Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation.

Agency for Healthcare Research and Quality. February 7, 2017.

Incomplete clinical notes create potential for treatment errors. This webinar discussed voice-generated electronic records as a strategy to augment clinical documentation and highlight natural language processing technologies as a component of this strategy.

Book/Report

Examining the Copy and Paste Function in the Use of Electronic Health Records.

Lowry SZ, Ramaiah M, Prettyman SS, et al. Gaithersburg, MD: National Institute of Standards and Technology, United States Department of Commerce; January 19, 2017. NIST Interagency/Internal Report (NISTIR)-8166.

Copying and pasting information in electronic health records can introduce risks. This report discusses a human factors study of the phenomenon to determine how the practice affects information distribution. The authors conclude that the problem does exist, describe its impact on situational awareness, and provide recommendations to improve safety associated with the copy-and-paste function.

Legislation/Regulation > Government Resource

ONC Health IT Certification Program: Enhanced Oversight and Accountability.

Federal Register. Washington, DC: Office of the National Coordinator for Health Information Technology, Department of Health and Human Services. 2016;81:72404-72471.

Requirements are needed to manage risks associated with health information technology systems. This final rule provides a framework for government review of technologies certified by the ONC Health IT Certification Program. The rule also covers certification guidance for testing laboratories. The regulations go into effect December 19, 2016.

Journal Article > Study

Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors.

Amato MG, Salazar A, Hickman TT, et al. J Am Med Inform Assoc. 2017;24:316-322.

Computerized provider order entry (CPOE) systems can effectively prevent many prescribing errors, but their overall safety benefit has not yet been fully realized. More widespread implementation of these systems has revealed new safety concerns. A prior study funded by the US Food and Drug Administration found that many of the safety issues associated with CPOE could be ascribed to poor usability of the systems, the lack of interoperability, and failure to track and learn from concerns identified by users. This follow-up study analyzed more than 1300 CPOE error reports to further classify the types of errors and their impact on patient care. Investigators determined that patients experienced delays in receiving medications due to these errors and were at risk of receiving duplicate medications or incorrect doses of medications. Similar to previous studies, the most common types of CPOE errors included problems with transmitting orders to the correct site of care, incorrect dose, or duplicate orders that were not detected by the system. A WebM&M commentary discussed an error that led to patient harm due to an incorrect default CPOE order.

Book/Report

Report on the Safe Use of Pick Lists in Ambulatory Care Settings.

Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.

Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.

Book/Report

Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report.

Graber ML, Bailey R, Johnston D. RTI International; Washington, DC: US Department of Health and Human Services, Office of the National Coordinator for Health Information Technology; 2016.

Health care organizations and clinicians are aware of the unintended consequences associated with health information technology. This report summarized the evidence to provide recommendations and help hospitals develop strategies to ensure safe use of health IT systems.

Journal Article > Study

Electronic health record adoption and rates of in-hospital adverse events.

Furukawa MF, Eldridge N, Wang Y, Metersky M. J Patient Saf. 2016 Feb 6; [Epub ahead of print].

Electronic health record (EHR) adoption was widely spurred by an assumption that it would improve patient safety. Although research suggests that EHRs have had an overall positive effect, unexpected consequences have occurred along the way and many problems remain. This retrospective study compared adverse events among patients in hospitals with fully electronic EHRs to those without such EHRs in place. After controlling for patient and hospital characteristics, patients exposed to a fully electronic EHR had 17% to 30% lower odds of having an adverse event. A recent PSNet interview with Dr. Robert Wachter discussed the role of health information technology in patient safety.

Book/Report

Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.

Lowry SZ, Ramaiah M, Taylor S, et al. Gaithersburg, MD: US Department of Commerce, National Institute of Standards and Technology; October 2015. NISTIR 7804-1.

Unintended consequences associated with usability of electronic health record (EHR) systems have the potential to negatively affect patient safety. This report outlines standards to enhance safety-related usability of EHRs by identifying root causes of use errors and addressing these weaknesses through human factors design.

Book/Report

Health IT Safety Center Roadmap.

RTI International. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2015.

The Institute of Medicine called for enhanced transparency in the reporting of health IT safety incidents to inform implementation and use of such technologies. This report reviews insights from a multidisciplinary task force that discussed how to design an entity focused on improving health IT–related safety that enables collaboration and learning.

Book/Report

Examining the Relationship Between Health IT and Ambulatory Care Workflow Redesign.

Zheng K, Ciemins EL, Lanham HJ, Lindberg C. Rockville, MD: Agency for Healthcare Research and Quality; July 2015. AHRQ Publication No. 15-0058-EF.

Ineffective implementation of health information technology (IT) can result in workarounds and other workflow changes that disrupt care delivery. This report examines how health IT implementation can affect clinician and staff workload in the ambulatory care environment, including increase interruptions and multitasking, and recommends workload considerations to enable staff to adapt to changes in practice.

Journal Article > Study

Meaningful Use stage 2 e-prescribing threshold and adverse drug events in the Medicare Part D population with diabetes.

Powers C, Gabriel MH, Encinosa W, Mostashari F, Bynum J. J Am Med Inform Assoc. 2015;22:1094-1098.

This analysis of Medicare data found that outpatient practices using electronic prescribing had fewer adverse drug events among their panel of patients with diabetes compared to practices not consistently using electronic prescribing. Although promising, this study does not address the many differences between practices that use electronic prescribing versus those that do not and the patients that select these disparate health care systems.

Newspaper/Magazine Article

Community-based health coaches and care coordinators reduce readmissions using information technology to identify and support at-risk Medicare patients after discharge.

Agency for Healthcare Research and Quality. Health Care Innovations Exchange. July 30, 2014.

This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.

Journal Article > Study

An analysis of electronic health record–related patient safety concerns.

  • Classic

Meeks DW, Smith MW, Taylor L, Sittig DF, Scott JM, Singh H. J Am Med Inform Assoc. 2014;21:1053-1059.

Health information technology is being rapidly utilized in the clinical environment, with recent data showing that most hospitals and clinics have implemented some form of electronic health record (EHR). In this context, this report from the Veterans Health Administration's Informatics Patient Safety Office is timely, as it uses a sociotechnical framework that takes into account both technical aspects and human factors engineering principles to analyze 100 safety incidents relating to the EHR. The authors found four categories of system flaws: mismatches between user needs and information displays, errors arising from software modification or updates, failures at the interface between the EHR and other clinical systems, and hidden dependencies within the system itself. Most of these issues were identified long after the EHR was implemented, highlighting the need for ongoing monitoring and optimization of EHRs to ensure their safety capabilities are being maximized. An error caused in part by lack of interoperability between two clinical information systems is discussed in a prior AHRQ WebM&M commentary.

Web Resource > Multi-use Website

OpenFDA.

Silverspring, MD: US Food and Drug Administration.

This Web site provides access to large publicly available datasets for adverse drug events to enable developers, researchers, and consumers to use this information when designing medication safety improvement plans or projects. Planned updates to this site include data on recalls and product documentation.

Book/Report

Promoting Patient Safety Through Effective Health Information Technology Risk Management.

  • Classic

Schneider EC, Ridgely MS, Meeker D, Hunter LE, Khodyakov D, Rudin R. RAND Health. Washington, DC: Office of the National Coordinator for Health Information Technology; May 2014. RR-654-DHHSNCH.

This report evaluates the implementation of a quality improvement initiative designed to characterize, track, and mitigate adverse events related to health information technology (IT). Investigators sought to determine challenges to engaging in identifying and addressing safety risks related to health IT in 11 health care organizations, and this publication outlines experiences and lessons learned from participating institutions. The authors call for greater awareness of safety risks related to health IT, better cooperation between risk management and health IT departments, identification of safety measures for health IT, incentives for health IT developers and vendors to improve health IT safety, and increased investment in risk management, health IT, and safety in ambulatory settings. The recommendations in this report serve as a blueprint for future practice and policy efforts to augment safety in the era of electronic health records.

Book/Report

FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework.

Washington, DC: Office of the National Coordinator for Health Information Technology, Federal Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.

While implementation of health information technology (IT) is widely recommended, research has raised the concern that it may lead to unintended consequences on patient safety. This draft report explores key recommendations for ensuring the safe use of health IT, such as the establishment of a "Health IT Safety Center" to test, disseminate, and promote assessment tools. The comment submission period is now closed.

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