Making Health IT A Team Player - VanQ 2009

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This talk addresses the impact of health IT systems on patient safety. In particular, how health IT systems intended to reduce medical error can introduce a new set of risks. Understanding why this is …

This talk addresses the impact of health IT systems on patient safety. In particular, how health IT systems intended to reduce medical error can introduce a new set of risks. Understanding why this is so is related to the need for better understanding of "human error", one that goes beyond simply blaming the users who are at the "sharp end" of the stick. In particular, health IT systems need to be good “team players”. One of the keys to making Health IT systems good team players is user-centered design (UCD). Another is ensuring that human factors are incorporated into safety risk management, as recommended by the FDA for medical devices.

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  • 1. Making Health IT a Team Player Ken Wong, Ph.D., Senior Systems Analyst McKesson Medical Imaging Group VanQ, January 29, 2009
  • 2. Dec 2008 – Health IT alert Technology-related adverse events also happen when health care providers and leaders do not carefully consider the impact technology can have on health care processes, workflow and safety. ─ Sentinel Alert Event, Issue 42, December 11, 2008, The Joint Commission 9/13/2009 2
  • 3. Overview Medical Error Unintentional Consequences of IT IT as a Team Player Being User Centered Conclusion 9/13/2009 3
  • 4. Medical Error
  • 5. To err is human As many as 98,000* people die each year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer and AIDS—making medical errors the fifth leading cause of death in this country. ─ To Err Is Human: Building a Safer Health System, Institute of Medicine, 1999 * 195,000 according to HealthGrades 2004 report 9/13/2009 5
  • 6. Human error … again? 9/13/2009 6
  • 7. Homer effect 9/13/2009 7
  • 8. But … Who put Homer in charge? How was Homer trained? Why did the system get into this state? What other safeguards are in place? Etc. 9/13/2009 8
  • 9. Approaches to human error2 Person approach System Approach ─ Aberrant mental processes ─ Humans are fallible ─ Human error as causes of ─ Human error as accidents consequences ─ Focus on those at the ─ Focus on upstream “sharp end” of the stick systemic factors ─ Goal: Reduce human ─ Goal: Build system variability defences 9/13/2009 9
  • 10. Swiss Cheese Model 9/13/2009 10
  • 11. Unintended Consequences of IT
  • 12. Can you read my mind? 9/13/2009 12
  • 13. IT to the rescue e.g., Computerized Physician Order Entry (CPOE) 9/13/2009 13
  • 14. We all fall down … we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. ─ Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors, Ross Koppel, et al., JAMA, March 2005 9/13/2009 14
  • 15. Human error .. yet again? 9/13/2009 15
  • 16. Unintended consequences of IT As a consequence, PCISs might not be as successful in preventing errors as is generally hoped. Worse still, PCISs could actually generate new errors. ─ Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors, Joan S. Ash, et al., JAMIA, Mar/Apr 2004 9/13/2009 16
  • 17. IT as a Team Player
  • 18. User (and workflow) is king E.g., FAA controller requirements ─ Conservative ─ Safety-critical Standard Terminal Automation Replacement System (STARS) From hf.tc.faa.gov 9/13/2009 18
  • 19. Workflow interruptus Health IT implicit assumptions4: ─ Workflow is continuous and uninterrupted ─ Complete and structured information entry/retrieval ─ Workflow is linear, clear and predictable ─ Making information available is sufficient notification 9/13/2009 19
  • 20. IT – savior vs team player IT as savior IT as team player ─ IT replaces fallible people ─ IT supports workflow ─ People adjust to IT ─ IT & people work together ─ Health IT “experiments”5 ─ User-Centered Design 9/13/2009 20
  • 21. Being User Centered
  • 22. Being User Centered (at MIG) Understand users and their workflows ─ Personas ─ Use Cases ─ Usability Testing Identify use-related hazards ─ Hazard Analysis 9/13/2009 22
  • 23. E.g., Usability Testing and Safety Run through anticipated tasks and scenarios: ─ Identify any usability problems ─ Collect quantitative performance data ─ Determine participants' satisfaction Incorporating safety: ─ Validate likelihood of identified hazards ─ Identify new hazards 9/13/2009 23
  • 24. Worlds collide Business Analysis User Software Healthcare Centered Engineering Design Safety 9/13/2009 24
  • 25. Conclusion
  • 26. Jan 2009 – Health IT chasm The nation faces a health care IT chasm that is analogous to the quality chasm highlighted by the IOM over the past decade. ─ Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, Institute of Medicine, 2009 9/13/2009 26
  • 27. Human error … never again? 9/13/2009 27
  • 28. Changing the world We cannot change the human condition, but we can change the conditions under which humans work ─ Human error: models and management, James Reason, BMJ, March 2000 9/13/2009 28
  • 29. References 1. To Err Is Human: Building a Safer Health System, Institute of Medicine, 1999 2. Human error: models and management, James Reason, BMJ, March 2000 3. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors, Ross Koppel, et al., JAMA, March 2005 4. Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors, Joan S. Ash, et al., JAMIA, Mar/Apr 2004 5. Hiding in plain sight: What Koppel et al. tell us about healthcare IT, Nemeth et al., JBI, June 2005 6. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, Institute of Medicine, 2009 7. Medical Device Use-Safety: Incorporating Human Factor Engineering into Risk Management, FDA, July 2000 9/13/2009 29