i2 Goals• Better Health, Better Care, Better Value through Quality Improvement – Further the mission of the Department of Health and Human Services – Highlight programs, activities, and issues of concern• Spur Innovation and Highlight Excellence – Motivate, inspire, and lead• Community building – Development of ecosystem• Stimulate private sector investment
Why focus on Reporting Adverse Events?• National Quality Strategy # 1 Priority –“Making care safer by reducing the harm caused in the delivery of care.”• Healthcare related errors continue to account for a significant amount of harm and death in the American health care system each year. – 1 in 3 hospitalizations have adverse events (AEs) that reach patients – We do not know about AEs in ambulatory settings
Most health care organizations collect AEs, but not very well• Estimates vary, but a recent study found that 14% of incidents that harmed Medicare beneficiaries in hospitals were reported. – Despite the fact that Medicare conditions of participation require incident reporting in most health care organizations (although not in ambulatory practices).
AHRQ’s Patient Safety Organizations (PSOs)Created by the Patient Safety Quality Improvement Act of 2005 (Patient Safety Act), PSOs – Allow health care providers to collect and analyze data without fear of legal discovery – Must protect the privacy of patients and reporting organizations.• Currently there are 75 PSOs listed with AHRQ. – Sponsors include hospital associations, health systems, collaborations of health systems (including academic medical center), national safety organizations and analytics vendors, liability insurers, professional associations, and single issue sponsors (e.g. medication safety, anesthesiology, and blood banks).
Common Formats and Reporting• AHRQ has created the Common Formats (CFs) v 1.2 for AE reporting using structured data, designed for reporting to multiple sources. – AHRQ’s PSO Privacy Protection Center hosts CFs and removes identifiable information to allow data aggregation in the Network of Patient Safety Databases.• Providers may also use CFs to send reports to state agencies and the Food and Drug Administration.
Increased reliance on PSOs• The IOM’s 2011 report Health IT and Patient Safety: Building Safer Systems for Better Care recommended voluntary reporting by providers to PSOs using AHRQ’s Common Formats as “best option.”• Under the ACA, by 2014 a hospital that contracts with a health plan that participates in an insurance exchange is required to have a patient safety evaluation system that includes reporting to PSOs.
The ChallengeDevelop an application that facilitatesthe reporting of patient safety events, whether implemented in hospital or ambulatory settings.
Description: App should . . .• Increase the ease of reporting patient safety events to the provider or parent organization;• Enable providers to import relevant EMR, PHR, and other electronic information, including screen shots, to the patient safety report and, in turn, submit an AHRQ Common Formats-compliant report to one or more PSOs;• Capture useful demographic and other relevant information from each patient including age, gender, race, and relevant diagnoses;
App should . . .(cont’d)• Capture information about the type of organization submitting the report using AHRQs PSO Information format• Reduce burden of reporting by enabling the option of submitting information in the patient safety report to public health or health oversight organizations, including state or federal programs or accrediting or certifying bodies.• Be platform-agnostic;• Leverage and extend NwHIN standards and services including, but not limited to, transport (Direct, web services), content (Transitions of Care, CCD/CCR), and standardized vocabularies.
Resources• Information on PSOs and Common Formats is available at http://www.pso.ahrq.gov/• The Common Formats v 1.2 is available on the PSO Privacy Protection Center website at https://www.psoppc.org/web/patientsafety
Judging Criteria1. Effectiveness of the system in facilitating patient safety event reporting including its compliance with AHRQ’s Common Formats2. Usability and design from the standpoint of all stakeholders3. Ability to integrate with electronic health records and other HIT data sources4. Creativity and innovation5. Leverage NwHIN standards including transport, content, and vocabularies
Timeline• Submission period begins: June,2012• Submission period ends: August 31, 2012• Winners announced: September, 2012