Speakers offer HIT safety plan details

The Office of the National Coordinator for Health IT (ONC) discussed the recently released Health IT Patient Safety Action and Surveillance Plan during a July 10 webinar, including goals of the plan and strategies for carrying out those goals.

“We’ve seen a rapid rise in adoption of health IT,” said Jodi G. Daniel, JD, MPH, director of the ONC’s Office of Policy Planning. The plan’s “goal is to advance patient safety in an increasingly health IT-enabled healthcare system.” The plan will help create the infrastructure required to support patient safety and take advantage of new opportunities for improving patient safety. “There are benefits and risks to any new technology,” Daniel said, and healthcare needs to be prepared for both.

ONC engaged the Institute of Medicine (IOM) to put together a technical expert panel and develop a report with recommendations with how HHS should address health IT and patient safety. The report, issued in 2011, identified many opportunities and called on HHS to develop an action and surveillance plan. ONC published a draft plan and considered the public comments when finalizing the plan.

The primary two objectives of the safety plan are to use health IT to make care safer and continuously improve the safety of health IT, Daniel said.

The plan focuses on three strategies—learn, improve and lead, said Jacob Reider, MD, ONC’s chief medical officer. “We want to increase the quantity and quality of data and knowledge about health IT safety. The IOM report was very explicit about how there isn’t sufficient knowledge of what’s happening in health IT safety. There are opportunities to improve and better understand exactly what’s happening in the domain of safety of the systems themselves—both in their creation and how they’re implemented.”

An important goal is standardized methods with which healthcare delivery organizations will report health IT safety events, Reider said. He described a process in which the health IT marketplace is under surveillance. If an organization has a concern, an accrediting body would receive reports from the healthcare delivery organization about potential hazards. ONC would monitor concerns and The Joint Commission would manage sentinel events.

The goal is a public-private process working to develop an improvement strategy. “We will continue to use the Meaningful Use program, standards and certification criteria to advance these priorities, and we will develop and disseminate tools and interventions.”

Finally, the program will investigate serious events and take action, Reider said. “We will train surveyors on health IT safety and that will become part of what CMS does in the future.” HHS will convene a committee that will prepare for and respond to health IT safety.

“We want to promote a culture of safety related to health IT,” he said. “We are pouring the foundation for a safety program.”

The Agency for Healthcare Research and Quality (AHRQ) and the FDA have revised the device common format which specified information to be reported on patient safety events involving a device to include specific details regarding health IT, said William B. Munier, MD, MBA, director of center for quality improvement and patient safety. “In the future, AHRQ is planning to expand its common formats for event reporting beyond the hospital and nursing home settings to ambulatory care, including clinics, doctors’ offices and surgery centers.”

When asked for an example of a health IT-related patient safety event, the speakers admitted they had no real definition—yet. Daniel said it would be an incident in which health IT contributed to a problem or health IT didn’t help to prevent an event or a human error. “There are a lot of different ways to look at this. We don’t have a definition.”

“We don’t know enough about the topic,” said Reider. “We need to do the root cause analysis so that when something happens or something almost happens—we’re also very interested in near misses—we know the source of the error. It’s very likely we will find situations in which the source is either the design or the implementation of health IT.”

Munier said patient safety events can’t be looked at as just IT-related. “Events rarely present as health IT events. The safety plan embraces looking at safety in its entirety.”