A Roadmap to Improving Health IT Safety

Andrew Gettinger | July 17, 2015

As we focus on making our health care ecosystem interoperable and building a continually improving learning health system, we need to ensure health IT enables safe, high quality care. We also know that doctors, nurses, and other clinicians that are all part of the care team are frustrated by health IT systems that are not coordinated or optimized to their workflow. Many of these systems will benefit from additional usability review, safety enhanced design and feedback from the user community. As part of our work on health IT-related safety, ONC has:

• Funded the Joint Commission’s Sentinel Event Alert and educational model In March 2015.

• Supported 10 webinars and four Issue Briefs in various areas related to health IT and patient safety as part of the RTI contract.

• Supported an analysis of health IT-related adverse events in two large adverse event databases held by patient safety organizations posted on HealthIT.gov in November 2014.

• Published the Safety Assurance for EHR Resilience (SAFER) Guides, nine self-assessment guides designed to help organization optimize the safety and safe use of health IT.

• Worked with the CMS Survey and Certification Group to educate surveyors so they can improve surveys in health IT-enabled hospitals and other facilities subject to CMS surveys, and

• Contracted for analysis of a malpractice closed claims database to better understand the role of health IT in malpractice claims to be released later this year.

Today, we took another important step in the national effort to help reduce possible health IT-related adverse events, or errors, with the release of the Health IT Safety Center Roadmap. The Roadmap was developed by RTI, International. We appreciate all the work that went into the development of the Roadmap and will review the recommendations to determine any next steps.

Consensus on the final Roadmap was reached after a series of advisory meetings of an RTI-selected task force of stakeholders. These stakeholders represent diverse interests ranging from clinicians and institutions that use health IT systems to developers, patient safety organizations (PSOs), governmental agencies in the field, academic researchers and other leaders in the field of patient safety and, in particular, health IT safety.

The task force did not propose for the center to have a regulatory function, but to promote health IT safety by convening interested parties, doing focused work to identify and disseminate best practices, and serve as the leading voice in addressing patient safety generally and health IT-related safety issues more specifically.

The idea of a Health IT Safety Center was originally brought forward in a series of proposals beginning with a report by the National Academy of Medicine (formerly the Institute of Medicine) titled Health IT and Patient Safety 2012.

In 2013, we issued the Health IT Safety Plan, and issued a status report in 2014, and continue to pursue the objectives of 1) using health IT to make care safer and 2) continuously improving the safety of health IT.

Then, in April 2014, as part of the draft Food and Drug Administration Safety and Innovation Act (FDASIA) Report, we joined with the Food and Drug Administration (FDA) and the Federal Communications Commission (FCC) in calling for the development of a Health IT Safety Center.

The Roadmap that was issued today envisioned the Health IT Safety Center as a trusted convenor of public and private stakeholders to create a learning health system for health IT and patient safety. The rationale was that the format envisioned would promote more safety content being disclosed in an environment of collaboration and shared purpose.

This work builds on many of the successes that have been achieved in helping to protect patients by organizations and individuals all across the nation. But it also points to some of the steps that need to be taken to respond to new errors that might have been introduced by the use of health IT; adverse events that need to be identified and the circumstances that lead to them addressed.

Over the course of the past year an intriguing fact emerged from the literature: Clinicians who were completely frustrated with the electronic health records that they are currently using, if given the opportunity, few said they would return to paper and pen-based records.

Now it is up to all of us who are working for the safe and secure use of health IT to move forward to a place where clinicians are not just satisfied with their work systems but where they couldn’t possibly imagine providing clinical care without them.