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Health IT Patient Safety and Surveillance and Action Plan. David R. Hunt, MD, FACS Medical Dir., HIT Adoption & Patient Safety ONC, Office of the Chief Medical Officer. ONC Pre-decisional Draft. Do not disclose. - PowerPoint PPT Presentation
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Health IT Patient Safety and Surveillance and Action Plan
ONC Pre-decisional Draft. Do not disclose.
David R. Hunt, MD, FACSMedical Dir., HIT Adoption & Patient SafetyONC, Office of the Chief Medical Officer
“Doubt is uncomfortable, but certainty is ridiculous… From the depth of our profound ignorance, let us do our best;…”
-- Voltaire Letter to Frederick William, Prince of Prussia
Ferney, November 28, 1770
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Goals
•Use Health IT to Make Care Safer
•Improve the Safety and Safe Use of Health IT
Goals:
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Goals Continued
• Addresses the role of health IT within HHS’s commitment to patient safety.
• Responds to ONC
sponsored IOM Report
• Builds upon existing authorities
• Seeks to strengthen patient safety efforts across government programs and the private sector
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Questions:
• Meaningful Use and Safety Risk Assessment: – To improve the safety of EHRs, should there be a
Meaningful Use requirement for providers to conduct a health IT safety risk assessment?
– Are there models or standards that we should look to for guidance?
• Meaningful Use and Reporting: – Should ONC require any form of reporting/reporting
verification under Meaningful Use?
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Questions:
• What should be the next steps in terms of EHR technology certification?– Certified EHR technology developers will be required to
publicly identify a method of incorporating user - centered design of eight certification criteria that have a high likelihood of helping to prevent medical errors (77 Fed Reg 54186-54189 (September 4, 2012)).
– Certified EHR technology developers will also be required to provide transparency regarding their approach to “quality management systems,” (77 Fed Reg 54189-54191 ((September 4, 2012))
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Background: 2011 IOM Report
•Response to ONC sponsored IOM Report Published Nov. 2011
•10 Recommendations
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Institute of Medicine, 2003
Patient Safety: Achieving a New Standard for Care: November 2003
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Fundamentals
In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb
safe·ty:
n. (sāf’tē), [L. salvus ] : the quality or condition of being free from harm, injury, or loss
Webster’s New 20th Century Dictionary Unabridged
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Claudius Galen(129 – 217)
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“Primum non nocere.”
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Hippocrates of Kos
“As to diseases make a habit of two things - to help, or at least, to do no harm.”
Epidemics I
Hippocrates of Kos (ca. 460 BC – ca. 370 BC)
Quality - Safety
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Quality = Help
Safety = Do no harm
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Goals
Goals
Health IT to Make Care Safer
Improve the Safe Use of Health IT
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Goals
•Health IT can improve patient safety in some areas such as medication safety; however, there are significant gaps in the literature regarding how health IT impacts patient safety overall
•Safer implementation and use begins with viewing health IT as part of a larger sociotechnical system
•All stakeholders need to work together to improve patient safety
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Patient Safety Action & Surveillance Plan
• Learning: Increasing the quantity and quality of data and knowledge about health IT safety
• Improving: Targeting resources and corrective actions to improve health IT safety and patient safety
• Leading: Promoting a culture of safety related to health IT
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Learning: Overview
Learning: Overview
• CliniciansEncourage and facilitate clinicians reporting of health IT – related safety events
• Developers Encourage health IT developers to embrace their shared responsibility for patient safety
• Safety Programs Incorporate health IT into existing safety programs, e.g. PSOs/AHRQ, CMS, AHRQ
ONC Pre-decisional Draft. Do not disclose.
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Learning: Safety Programs
Learning: Safety Programs
Reporting• AHRQ/PSOs
Accrediting• ONC-ACB• CMS
ONC Pre-decisional Draft. Do not disclose.
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Patient Safety Action & Surveillance Plan
• Learning: Increasing the quantity and quality of data and knowledge about health IT safety
• Improving: Targeting resources and corrective actions to improve health IT safety and patient safety
• Leading: Promoting a culture of safety related to health IT
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Improving
• AHRQ/PSOAHRQ will provide technical guidance to help PSOs work with providers to mitigate harm and improve safety through health IT
• CMSCMS will provide guidance to surveyors and accreditation organizations to recognize health IT – related adverse events when conducting surveys on CMS’ behalf
• ONC-ACBsONC-ACBs will conduct live testing in clinical environments to determine whether clinician safety complaints are addressed and whether EHR safety features are performing adequately.
Improving:
ONC Pre-decisional Draft. Do not disclose.
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Patient Safety Action & Surveillance Plan
• Learning: Increasing the quantity and quality of data and knowledge about health IT safety
• Improving: Targeting resources and corrective actions to improve health IT safety and patient safety
• Leading: Promoting a culture of safety related to health IT
Is Safety Meaningful?
“We cannot change the human condition, but we can change the conditions under which humans work.”
James ReasonHuman error: models and management
BMJ 2000; 320: 768-7022
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THANK YOU.
Thank You
Contact Information
www.healthit.gov
