Transcript Slides - Health IT Safety Center Roadmap

RTI International
Health IT Safety Webinar Series
Patient Safety Organizations (PSO)
and Health IT Safety
March 19, 2015
1:00-2:30pm EST
RTI International is a trade name of Research Triangle Institute.
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www.rti.org
RTI International
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RTI International
Health IT Safety Webinar Series
This series of 10 webinars focused on health IT and patient
safety issues will occur monthly through September 2015.
These webinars are funded by the Office of the National
Coordinator for Health Information Technology (ONC) and
are being conducted by RTI International, a non-profit
research organization, as part of a year-long project to
develop a road map for a Health IT Safety Center for ONC
(contract HHSP23320095651WC).
Additional information is available at:
www.healthitsafety.org
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RTI International
Today’s Presentations
Peggy Binzer, JD, Executive Director, Alliance for Quality
Improvement and Patient Safety and Shareholder Polsinelli
PC: “How Patient Safety Organizations (PSOs) Contribute to
Health IT Safety and Improved Patient Care”
Ronni Solomon, JD, Executive Vice President and General
Counsel at ECRI Institute: “Evidence from PSOs on
Improvement”
Drew Ladner MA, MBA, President & CEO of PSO Pascal
Metrics: "Sustainable System-wide Safety: Enabling PSOs to
Improve Patient Safety in a Value-driven Environment“
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(Moderator) Jonathan S. Wald, MD, MPH, FACMI, Director,
Patient-Centered Technologies, RTI International
RTI International
Today’s Speakers
Peggy Binzer, JD, is the Executive Director for the Alliance for
Quality Improvement and Patient Safety. She is a legal counselor and
a veteran public policy strategist who works closely with health
systems, health information technology and medical device
companies, pharmacies, and others to improve the quality and safety
of patient care.
Presentation:
“How Patient Safety Organizations (PSOs) Contribute to Health IT
Safety and Improved Patient Care”
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Patient Safety Organizations (PSOs)
and Health IT Safety: Safety Culture
Framework
Polsinelli PC. In California, Polsinelli LLP
Peggy Binzer
Alliance for Quality
Improvement and Patient
Safety
www.allianceforqualityimprov
ement.org
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Alliance for Quality Improvement and
Patient Safety
AQIPS is the nation’s leading professional
association for Patient Safety Organizations
(PSOs) and their healthcare provider
members that leads efforts to measurably
improve patient safety and the quality of
patient care by fostering the ability of
providers to implement a culture of safety
and high reliability.
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The Patient Safety and Quality
Improvement Act
Quality
Information
PSQIA
Excellent
Health Care
Quality &
Safety
 The Patient Safety and Quality
Improvement Act of 2005
(PSQIA), also known as The
Patient Safety Act, encourages
providers to confidentially share
quality information to improve
the quality and safety of health
care delivery in a culture of
safety - without fear of litigation
or harm to professional
reputations. In a safety culture,
providers report incidents more
often and provide more
information without fear of
reputational harm or discipline.
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Patient Safety Organization
 A means of furthering the ability to
accelerate the identification of,
understanding of, and implementing
evidence-based solutions for, preventable
harm.
 Oversight by the Center for Quality
Improvement and Patient Safety, AHRQ.
 PSOs work with providers throughout the
entire health care continuum that use
different Health IT Systems in providing
patient care.
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Protections for Data and Health Care
Providers
† Privilege for Patient Safety Work Product:
 Information is not subject to subpoena, discovery or admission into
evidence
 Cannot be used in a State disciplinary proceeding
 Provides federal liability protections to providers:
– Federal privilege and confidentiality protections cross state lines
– Federal privilege preempts state tort laws but not state reporting laws
– Establishes a federal peer review privilege for all providers
† Confidentiality – The Act places a statutory requirement on providers
not to disclose “Patient Safety Work Product,” except under certain
circumstances and imposes civil money penalties against any person or
principal who knowingly or recklessly violates the confidentiality
provisions
† PSO Protections – PSWP developed by the PSO cannot be compelled.
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Protecting Patient Safety:
Current Practice
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Report incidents
Identify and analyze problems
Collect and analyze data
Create and implement corrective actions
Identify and address trends
…..all this stays within the hospital
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Patient Safety Organizations
 Break the silos and promote transparency
through the sharing of case studies and
best practices among health care entities,
healthcare professionals, and patients.
 Congress intended PSOs to share trends,
best practices, clinical protocols, clinical
solutions throughout healthcare
continuum.
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PSOs Develop Innovative
Models of Care
PSQIA is flexible “to accelerate the
development of new, voluntary providerdriven opportunities for improvement” and to
“set the stage for breakthroughs in our
understanding of how best to improve patient
safety.”
Patient Safety and Quality Improvement, Proposed Rule, 73 Fed. Reg. 8112, 8113
(February 12, 2008).
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Health IT and Patient Safety: Building
Safer Systems for Better Care
Institute of Medicine, 2011
 “To fully capitalize on
the potential that
health IT may have
on patient safety, a
more comprehensive
understanding of how
health IT impacts
potential harms,
workflow, and safety
is needed.”
 “PSO may be the best
option for collecting
health-related IT
reports from
healthcare providers”
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PSO: System for Continuous Quality
Improvement
 ONC’s HIT Patient Safety Action and
Surveillance Plan - support the use of
PSO’s to meet two core objectives:
– To use HIT to make care safer and
– To continuously improve the safety of HIT
 FDA, FCC and ONC’s FDASIA report
support the use of PSOs
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HIT Makes Care Safer
 AMC PSO, a Component of Risk
Management Foundation of the Harvard
Medical Institutions, mission is to function
as a national convener of clinicians and
health care organizations to collect,
aggregate, and analyze data, in a secure
environment in an effort to identify and
reduce the risks and hazards associated
with patient care.
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Test Results Management
 AMC PSO convened key leaders and experts to address
test results management. Literature shows that 25% of
all outpatient medical errors can be attributed to the test
result follow-up process.
 Performed a review of case studies and a focused review
of literature to identify risks associated with Tests
Results Management.
 Developed recommendations for improved electronic
Results Management in electronic health records.
“Electronic results management systems have been
shown to reduce delays and decrease incomplete followups, but maximizing optimization requires integrating
the technology with routine clinical workflow.”
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Continuously Improve Quality of HIT
 The Alliance for Patient Medication Safety
is a component PSO of the National
Alliance of the State Pharmacy
Associations. The mission of APMS is to
foster a culture of quality within the
profession of pharmacy that promotes a
continuous systems analysis to develop
best practices that will reduce medication
errors, improve medication use and
enhance patient care.
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E-prescribing Experience Portal
Developed open portal for providers to report
e-prescribing challenges (PEER PORTAL)
Goal to improve the quality and effectiveness
of electronic prescribing technologies.
1) Identify the types and quantify the problem(s) pharmacies and prescribers
experience with e-prescribing through a data collection and analysis
mechanism,
2) Estimate the financial impact of e-prescribing by including “time spent in
resolution,”
3) Develop recommendations for possible solutions
University of Arizona School of Pharmacy, State
Pharmacy Associations, Community Pharmacy
Foundation - Developed report, training and
publication
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E-Prescribing Reporting Portal (PEER Portal)
Collects Your E-prescribing Experiences
 The pharmacist was the FIRST
person to identify the error in
76% of reports
 The majority of reports
involved problems with
SIG/directions and quantity
selection (see figure to right)
 In 39% of the reports the
incidents reported were “near
misses” but in 4% the incident
reached patients
 24% of respondents indicated
that the time elapsed from
issue identification until
resolution was over 8 hours
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New Initiative to Continue the
Learning
 Quantify and characterize e-Rx errors
reported to the Pharmacy and Prescriber eprescribing Experience Reporting (PEER)
Portal between 2012 and 2014
 Examine relationship between standards and
types of errors
 Use the results to work with e-prescribing
stakeholders
 Provide training to community pharmacists
about potential procedural changes that can
prevent e-Rx errors
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HIT/Patient Safety Shared Responsibility
 Providers uncover potential issues or unintended
consequences and can discern how HIT can make
health care safer in their health care systems.
 EHR developers understand how EHR systems
work and therefore will help PSOs and providers
be more successful in understanding the root
causes of suspected incidents so they can be
prevented in the future and can modify the
systems to make care safer.
 PSOs can bring the two together to collaborate in a
safety culture to improve workflows, systems,
interfaces, interoperability and HIT quality to
improve patient care and save lives.
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Mistakes can best be prevented by
designing the
health
system
at
all
to do it right.
levels
to
make
it
safer--to
make
it
IOM Report: To Err is Human
harder for people to do something
wrong and easier for them to do it
right.
-IOM To Err is Human
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RTI International
Today’s Speakers
Ronni Solomon, JD, serves as Executive Vice President and General
Counsel at ECRI Institute. She has overall responsibility for ECRI
Institute’s legal affairs and healthcare safety, risk and quality
initiatives. She has over 20 years of experience in healthcare law, risk
management, and patient safety. She is a member of ECRI Institute’s
executive team. She developed and led many ECRI Institute initiatives
and programs for the public and private sectors on patient safety and
quality of care, including ECRI Institute PSO, a federally certified
patient safety organization.
Presentation:
“Evidence from PSOs on Improvement”
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Partnering on Health IT
Patient Safety
Ronni Solomon
ECRI Institute
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Do you think your EHR or the way it’s
used has been associated with
adverse events in your organization?
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Case Study 1
• On admission, the patient’s weight was
documented as 40 kg. The patient actually
weighed 40 pounds. The patient’s weight can
be entered in kilograms or pounds.
• The patient’s medication dose was calculated
based on the patient’s weight in kilograms.
• Pharmacy caught the error and corrected the
dose based on the patient’s true weight.
HIT issue?
Should this be reported?
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Case Study 2
• The surgeon tried to access a patient’s radiology study
from the PACS system in the OR. The display would
only show a blue screen. The patient’s time under
anesthesia was extended while we tried to get the
computer display to work.
HIT issue?
Should this be reported?
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Case Study 3
• A physician ordered extended-release morphine to be given
to a patient with cancer every 12 hours to control pain. In
addition, there was an order for a smaller dose of immediaterelease medication for breakthrough pain.
• The patient complained of pain and was given both
formulations.
• The patient had a respiratory arrest.
• Upon further investigation
– eMAR truncated the display for morphine orders
– Providers could not view information on formulations
HIT Issue?
Should it be reported?
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Case Study 4
• Provider begins to enter
medication dose. Typed
“10” for 10 MG dosage.
• Highlighted list appears,
software auto-selected
“100.”
• The provider selects the
highlighted dosage
HIT event? Report?
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Case Study 5
• Provider documents care in the free text fields of the EHR
• Documentation included a medication order and a lab order
Is this an HIT-related issue?
Should this be reported?
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Case Study 6
• The medication management system allows the
pharmacist to navigate off one patient profile and pull up
another patient profile. An incorrect medication order was
placed in the wrong patient’s profile. The patient received
incorrect medications as a result.
Is this an HIT-related issue?
Should this be reported?
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Health IT and Patient Safety
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Health IT and Patient Safety
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Top Five Health IT-Related Events
1. System interface issues
2. Wrong input
3. Software issue—system
configuration
4. Wrong record retrieved
5. Software issue-functionality
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The Importance of….
Identifying HIT events
Communicating HIT
events
Understanding why they
happen
Fixing the problems
SHARE LEARN PROTECT
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Multi-stakeholder Partnership Convened in 2014
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Working Together:
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©2014 ECRI Institute. ECRI Institute prohibits the direct dissemination, posting, or republishing of this work, without
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Purpose of the Partnership
Making healthcare IT safer together
Objectives
• Establish a non-punitive environment for sharing and
learning
• Test a collaborative model for collecting and analyzing
safety issues
• Achieve robust stakeholder engagement
• Share best practices and lessons learned
• Evaluate two health IT reporting taxonomies
• Inform the national safety strategy for health IT
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Approach
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Polling Question
What do you see as the top HIT safety issues?
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Focused Workgroups: Best Practices
Risks
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Old data
treated as
current
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Other patient’s
data gets into
wrong chart
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“Note bloat”
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Semblance of
synthesis
Benefits
• Efficiency
• Productivity
• Memory-jogging
or prompting
when used as
template
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Next Steps in 2015
Publish Proceedings – January
• Partnering for Success, Sep 2014
Activate workgroup – February
• Copy and Paste
Disseminate best practices June
• Educational campaign
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8-dimensional Socio-Technical Model of Safe
& Effective Health IT Use
Sittig Singh QSHC 2010
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Tools – Safer Guides
• Developed by Dean Sittig,
Hardeep Singh & Joan Ash for
ONC
• Proactive approach to HIT safety
• Based on best practices & explicit
standards
• Available at
http://www.healthit.gov/safer/
Foundational Guides
• High priority practices
• Organizational responsibilities
Infrastructure
• Contingency planning
• System configuration
• System interfaces
Clinical Processes
•
•
•
•
Patient identification
CPOE/CDS
Test results reporting & follow-up
Clinician communication
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Tools – How to Identify and Address Unsafe
Conditions
• Developed by ECRI Institute for
ONC
• Based on Deep Dive findings
• Education, slide deck
• Available at
http://www.healthit.gov/buzzblog/electronic-health-andmedical-records/guide-identifyaddress-unsafe-conditions-health/
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Do you think your EHR or the way
it’s used has been associated with
adverse events in your
organization?
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Thank You
Ronni Solomon
Executive Vice President and General Counsel
ECRI Institute
[email protected]
www.ecri.org
©2 0 1 5 E CR I I N S T I T U T E
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RTI International
Today’s Speakers
Drew Ladner, MA, MBA, is President & CEO of Pascal Metrics, a
Patient Safety Organization (PSO) serving a large community of
leading healthcare systems and stewarding some of large patient
safety data sets. A pioneer and innovator in patient safety and health
IT, Pascal was the first PSO to be certified and successfully audited to
use real-time clinical data to identify, track, and manage all cause
harm. He holds an MBA from Harvard Business School, an MA in
theology from the University of Oxford, and a BSFS in international
economics from Georgetown University’s School of Foreign Service.
Presentation:
"Sustainable System-wide Safety: Enabling PSOs to Improve Patient
Safety in a Value-driven Environment“
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REAL-TIME PATIENT
SAFETY
ORGANIZATIONS:
Enabling Next Generation Patient
Safety in the Age of Health IT
MARCH 19, 2015
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© Pascal Metrics 2015
AGENDA
THE PREVALENCE OF HARM
THE ROLE OF PSOS
OPPORTUNITIES FOR PSOS
HEALTH IT: THE NEW ENABLER
OPERATIONS & IMPROVEMENT
THE CASE FOR PSOS
FUTURE DIRECTIONS
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© Pascal Metrics 2015
10X MORE PREVENTABLE HARM
SINCE IOM ‘99
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© Pascal Metrics 2015
TRIGGER METHODOLOGIES UNCOVER
10 TO 100 FOLD MORE ADVERSE
EVENTS THAN INCUMBENT SYSTEMS
Exhibit 4: Adverse Event Detection, by Severity Level and Hospital
IHI Global Trigger Tool
AHRQ Patient Safety Indicators
Hospital Voluntary Reporting System
E - Temporary Harm
204
23
0
F - Increased Length of Stay
124
7
2
8
1
2
14
0
0
4
4
0
354
35
4
SEVERITY LEVEL
G - Permanent Harm
H - Intervention Needed to Sustain Life
I - Death
TOTAL
Source: Classen et al, Health Affairs 2011
IHI GTT Definition of Patient Harm
“Unintended physical injury resulting from or contributed to by
medical care that requires additional monitoring, treatment or
hospitalization, or that results in death.”
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© Pascal Metrics 2015
THE ROLE OF PSOs: THE LAW
To reduce preventable patient harm by enabling
clinical review of patient safety events for the
purpose of improvement
• Reporting
• Analysis
• Aggregation
• Feedback
• Learning
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© Pascal Metrics 2015
THE ROLE OF PSOs: THE IOM
Recommendations 7-8
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© Pascal Metrics 2015
CURRENT OPPORTUNITIES
FOR PSOs
In mandate to use culture of safety to generate insight and
feedback on how to improve safety, opportunities include:
• Taking advantage of and building upon event reporting
• Using not just retrospective data but current &
prospective
• Validating value with business cases
• Empowering clinicians to anticipate harm
• Facilitating measurable learning with accurate data
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© Pascal Metrics 2015
10 YEARS LATER: A MODEL SHIFT
Library
Control Tower
The Enabler:
Real-time clinical data
delivered by health IT
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© Pascal Metrics 2015
THE IOM: CULTURE IS CORE
TO SAFETY
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© Pascal Metrics 2015
CULTURE PREDICTS SAFETY
OUTCOMES
1. Re-admissions
2. BSIs, VAPs, UTIs,
3. Patient satisfaction
4. Medication errors
5. AHRQ Patient Safety Indicators
6. Malpractice claims
7. Back injuries
8. Nurse turnover & absenteeism
9. Nurse satisfaction
10. Glycemic control and others
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Culture-to-Outcomes
Linkage:
•Hansen et al. (2011)
•Curry et al. (2011)
•Pettker et al. (2009)
•Singer et al. (2009)
•Vogus & Sutcliffe (2007)
•Mark et al. (2007)
•Naveh et al. (2006)
•Hofmann & Mark (2006)
•Katz-Navon et al.
(2005)
© Pascal Metrics 2015
PSO CONTROL TOWER: PROVIDING
ACTIONABLE INFO TO SUPPORT
COMPLEX PATIENT SAFETY OPERATIONS
System Level
Leadership
PSO
Hospital Level
Leadership
Quality/Safety/Risk Team
Unit Level Team
ICU
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OR
ED
MS
OB
Real-time
HL7 data
feeds from
provider
health IT
systems to
cloud
© Pascal Metrics 2015
REAL TIME HEALTH IT:
THE NEW ENABLER
Applying real-time clinical data results in the following value for patient safety
Diversity of Data ► Accuracy
Timeliness of Data ► Actionability
Linking of Data ► Sustainability
Modeling of Data ► Predictability
Sharing of Data ► Learning
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© Pascal Metrics 2015
REAL TIME SAFETY
MEASUREMENT
Example: Harm Reporting & Analytics
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© Pascal Metrics 2015
REAL TIME SAFETY
MONITORING
Example: Harm Monitoring Interface
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© Pascal Metrics 2015
REAL TIME SAFETY PREDICTION:
THE NEXT FRONTIER
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© Pascal Metrics 2015
HEALTH SYSTEM VALUE:
SAFETY ACROSS CONTINUUM
Clinical
Both near misses and serious events found comprehensively if also using
real-time method providing actionable intelligence to clinical and executive
leaders.
Financial
Nine-figure cost reduction opportunities available for health
systems. Single-digit million dollar preventable harm opportunities
available for medium-sized hospitals.
Regulatory
Regulators moving towards safety-related reimbursement
based on electronic measures.
Learning System
Efficiently improve patient safety “slice” of population
management and unit-level care by measuring, tracking,
and managing preventable harm -- coordinating across
the continuum.
Moral
CLINICAL
VALUE
FINANCIAL
VALUE
REGULATORY
VALUE
LEARNING SYSTEM VALUE
MORAL VALUE
Classen et al. Health Affairs 30, No. 4 (2011):
Pascal Analysis based on AHRQ estimates and published harm rates
Health Affairs 30, No. 4 (2011)
D. Classen MD., National Clinical Lead. National collaborative to automate
safety measurement and improvement. Pascal Metrics, AHA, AHRQ.
It’s the right thing to do for patients
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© Pascal Metrics 2015
FUTURE DIRECTIONS
Opportunities for Learning & Action
• Measurement
– Types
• Improvement
– Targeting
• Learning
– Transparency
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© Pascal Metrics 2015
RTI International
Questions and Wrap Up
Speaker Contact
Information
Next Webinar
Peggy Binzer
pbinzer@allianceforqualityimpro
vement.org

Ronni Solomon
[email protected]
Drew Ladner
[email protected]
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CPOE*, CDS**, and Health IT
Safety
April 23, 2015
1-230p EDT

Please visit:
www.healthitsafety.org or
contact [email protected] for
more information on the entire
webinar series
* Computerized Provider Order Entry; **Clinical Decision Support