Health IT and Patient Safety Building Safer Systems for Better Care (2012) / Chapter Skim
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4 Opportunities to Build a Safer System for Health IT
4 Opportunities to Build a Safer System for Health IT
Pages 77-114
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From page 77... ...
Adhering to well-developed practices for design, training, and use can minimize safety risks. Building safer health IT involves exploring both real and potential hazards so that hazards are minimized or eliminated.
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From page 78... ...
Effective design and development drive the safe functioning of the products as well as determine some aspects of safe use by health professionals. Collaboration among users and vendors across the continuum of technology design, including embedding products into clinical workflow and ongoing product optimization, represents a dynamic process characterized by frequent feedback and joint accountability to promote safer health IT.
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From page 79... ...
An inflexible order sequence may require the provider to hold important orders in mind while navigating through mandatory screens, increasing the cognitive workload of com
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In addition, the problem list in some electronic health records (EHRs) is limited to structured International Classification of Diseases (ninth revision)
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From page 81... ...
One report, NIST Guide to the Processes Approach for Improving the Usability of Electronic Health Records, introduces the basic concepts of usability, common principles of good usability design, methods for usability evaluation and improvement, processes of usability engineering, and the importance of organizational commitment to usability (NIST, 2010b)
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From page 82... ...
Even if clinicians are aware of these issues and become more diligent, health IT products that are not designed for users' needs create addi tional cognitive workload, which, over time, may cause the clinician to be more susceptible to making mistakes. Personal communication, Christine A
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. NIST released draft guidance on design evaluation and human user performance testing for usability issues related to patient safety, Technical Evaluation, Testing and Evaluation of the Usability of Electronic Health Records.
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From page 84... ...
One such example is the electronic capture of gestures observed in an operating room that is then recorded as activities requiring no interruption of the clinician's working within the sterile field. To support usability within EHRs, Shneiderman has identified eight heuristically and experientially derived "golden rules" for interface design (Shneiderman et al., 2009)
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From page 85... ...
85 OPPORTUNITIES TO BUILD A SAFER SYSTEM TABLE 4-1 Eight Golden Rules for Interface Design Principles Characteristics Strive for – Similar tasks ought to have similar sequences of action to consistency perform, for example: • Identical terminology in prompts and menus • Consistent screen appearance – Any exceptions should be understandable and few Cater to universal – Users span a wide range of expertise and have usability different desires, for example: • Expert users may want shortcuts • Novices may want explanations Offer informative – Systems should provide feedback for every user action to: feedback • Reassure the user that the appropriate action has been or is being done • Instruct the user about the nature of an error if one has been made – Infrequent or major actions call for substantial responses, while frequent or minor actions require less feedback Design dialogs – Have a beginning, middle, and end to action sequences to yield closure – Provide informative feedback when a group of actions has been completed – Signal that it is okay to drop contingency plans – Indicate the need for preparing the next group of actions Prevent errors – Systems should be designed so that users cannot make serious errors, for example: • Do not display menu items that are not appropriate in a given context • Do not allow alphabetic characters in numeric entry fields – User errors should be detected and instructions for recovery offered – Errors should not change the system state Permit easy – When possible, actions (and sequences of actions) should reversal of actions be reversible Support internal – Surprises or changes should be avoided in familiar behavlocus of control iors and complex data-entry sequences Reduce short-term – Interfaces should be avoided if they require users to memory load remember information from one screen for use in connection with another screen
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From page 86... ...
Interoperability with personal health record systems and other patient engagement tools is also desirable, both in delivering data to patients and in collecting information from any patient-operated systems. Failure to achieve interoperability has considerable risks for patient safety.
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87 OPPORTUNITIES TO BUILD A SAFER SYSTEM TABLE 4-2 Aspects of Interoperability and Their Impact on Patient Safety Aspects of Impact on Interoperability Definition Patient Safety Ability to exchange the Allows for electronic Software components that physical data stream communication between cannot communicate with of bits (Hoekstra et al., software components each other force users 2009) that represent to reenter data manually, relevant information which: – Detracts from time better used attending to patient safety and – Increases opportunities to enter misinformation Ability to exchange data Ability for software system The loss of meaning in without loss of semantic to properly work when received data compromises content modules from different patient safety vendors are "plugged in" Accept "plug-ins" Semantic content refers – The inability to use mul seamlessly to information that allows tiple modules within one software to understand organization decreases the electronic bits the likelihood that users can provide their patient information to another health IT product – Lack of "plug-in" interop erability means that the user does not have the ability to select modules from multiple vendors that may perform a spe cific function more safely Display similar – Different health IT When information is dis information in the products display played inconsistently across same way similar information organizations, the user in similar ways must reconcile the different representations of the in – Systems are consistent formation mentally, which: in matters such as screen position of – Requires an increased fields, color, and units cognitive effort that could be better used toward safe care and – Increases the chance that a user may make a mistake
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From page 88... ...
Making data exchangeable is primarily the responsibility of the vendors who produce the code. The committee believes guidelines need to be developed to support safe interoperability (see Box 4-2)
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From page 89... ...
; • Less access to technical support to keep their systems running reliably; • Less ability to appreciate, purchase, and afford the amount of train ing and/or vendor support needed for an optimal implementation; • Less capacity to monitor for and recognize new failure modes asso ciated with implementation of health IT; and • An absence of standard recommendations on a variety of key implementation issues such as what to do with paper, and whether to implement as a "big bang" or in phases. 1 Ninety-three percent of all primary care physicians work in organizations of 10 physicians or fewer; of those, about half practice in organizations with 1 to 2 physicians (Bodenheimer and Pham, 2010)
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90 HEALTH IT AND PATIENT SAFETY BOX 4-3 A S mall Provider's Experience with E lectronic Health Records (EHRs) It was mostly on my initiative to implement an EHR.
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. Nonprimary care providers may also be more likely than primary care providers to have clinical support staff who assist with data entry, data aggregation, and data extraction in the routine course of patient care.
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Opportunities exist for vendors, aided by users, to improve safety in the different phases or activities of the software design and development life cycle. Although in theory these activities are identifiable, in practice the boundaries between them are not well defined and require varying levels of intensity to complete.
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Clinicians communicate their needs in detailed statements based on evidence of safe practices whenever possible. Clinicians and software developers need to communicate safety needs and expectations for the clinical environment and the health IT product.
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94 HEALTH IT AND PATIENT SAFETY TABLE 4-3 Health IT Vendor Design Activities Opportunities to Activities/Phases Features Improve Safety Requirements – Developers articulate – Clinicians communicate Activity what the software must their needs do and the circumstances – Clinicians identify data under which such behavior that must be captured is appropriate or imported, with any – Developers articulate what requirements for conversion the software must not do and validation such as full when safety is an issue text entries – End users of the software – Prototype testing must be intimately – Safety analyses involved in all aspects of the requirements activity Software – Involves actual program- – Iterative testing identifies Development ming or coding that re- unintended consequences flects the software design for early revisions and informs the next round – Software development of development is often undertaken iteratively with testing – Results from testing are used to inform another round of software development Design of User – Designers define the – Clinicians give feedback Interface Activity structure of the software to designers about effec tiveness or improvements – Software engineers decide needed for usability testing on the appropriate techni cal approaches and solve problems conceptually
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From page 95... ...
Best practices for developing software emphasize systematicity and quality control. Software developers should identify and record significant risks of failure in development or in performance and articulate a plan to reduce them.
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From page 96... ...
Shneiderman has identified eight heuristically and experientially derived "golden rules" for interface design that, if followed, support the principles of EHR usability (Shneiderman et al., 2009) , including consistency for similar tasks; universal applicability for a wide range of expertise; feedback for every user action; communicating closure of an action sequence; design to prevent errors; allowing easy reversal of actions; avoiding complex data entry and retrieval sequences; and reducing memory load (see Table 4-1)
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From page 97... ...
To maximize the user–designer feedback loop, EHR products might include a "report here now" button on each screen wherein the user can indicate that a display was confusing, a workflow was cumbersome, or some other way that the design did not support optimal clinical care. Software Implementation and Postdeployment Activities Portions of the software life cycle led by vendors in partnership with users influence safer use of health IT such as training prior to implementation, addressing problems that appear during testing and implementation of software, and planning for the ongoing maintenance and upgrade activities that directly impact users.
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From page 98... ...
• Design (e.g., a dysfunc tional architecture) Upgrade Activity Modifying the software – Planning for upgrades with to meet new requirements adequate backup systems that may emerge over is a requirement time, such as enabling the – Planned safety testing software to work with new of operational system hardware on routine ongoing basis NOTE: Traditionally, these activities are called "phases" (e.g., requirements phase, design phase)
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From page 99... ...
OPPORTUNITIES TO IMPROVE SAFETY IN THE USE OF HEALTH IT Safer use is intimately linked to safer design. For example, safer use of an EHR evolves from effective planning and deployment with testing and management of human–computer interface issues, to optimization of tools and processes to improve the application of the system.
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. For users, the opportunities to improve safety of health IT can be divided into the following phases: acquisition, clinical implementation (which includes planning and goal setting, deployment, stabilization, optimization, and transformation)
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101 OPPORTUNITIES TO BUILD A SAFER SYSTEM TABLE 4-5 Health IT User Activities Opportunities to Activities/Phases Features Improve Safety Acquisition – Selecting and attaining – Perform self-assessments a system that will con- and strategic planning nect data from clinical before the decision to and other related IT and purchase health IT support an organization's – Ensure that the resources clinical and administrative needed to support adoption workflows and implementation of health IT products are available Clinical – Planning and goal setting – Analyze existing workflow, Implementation • Assessing needs envision the optimal • Selecting systems workflow, and select based on functionality the automated system • Testing quality before that achieves the optimal go-live automated workflow – Deployment – Establish mechanisms • Training and demon- and metrics to identify, strating competence escalate, and remediate of users patient safety issues • Converting data – Testing locally to verify conversions prior safety, interoperability, to go-live security, and effectiveness • Minimizing mix of – Monitor and measure the electronic and paper dependability, reliability, functions and security of the installed • Planning orderly system implementation – Take steps to resolve any – Stabilization potential hazards • Evaluating human computer interactions – Learn and improve patient for effective design safety by utilizing data and interface generated by the health • Correcting functions IT system that disrupt workflow • Minimizing downtime • Planning maintenance – Optimization • Engaging clinical decision support • Retraining for proper and best use • Readdressing changes needed for workflow improvements – Transformation • Measuring improved clinical and efficiency outcomes continued
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From page 102... ...
These antecedents to acquisition will help an organization prepare for both acquisition and implementation of health IT and optimize outcomes in subsequent phases of the implementation life cycle. Unfortunately, sometimes the due process of strategic planning is in place, but the evaluative decision-making model is inadequate.
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From page 103... ...
Clinical Implementation Successful deployment of a health IT product and its effective use are intended to achieve seamless internal information flow as well as to enhance performance in safety, quality, service, and cost. Safe implementation of health IT is a complex, dynamic process that requires continual feedback to vendors and investment by health care organizations.
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From page 104... ...
Mechanisms to identify, escalate, and remediate patient safety issues need to be in place as the organization proceeds to the deployment stage. Metrics to be considered at this stage include ensuring that organization leaders have identified objectives, teams, and resources committed to the implementation.
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From page 105... ...
Factors That Enhance or Detract from Patient Safety – Are users actively involved – Is big bang or sequential – How are "downtimes" – What clinical decision sup- – How do we learn about in the acquisition and design safer? managed?
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From page 106... ...
During this stage, the organization ought to be monitoring the dependability, reliability, and security of the installed system and taking steps to resolve any potential hazards. More specific measures of these system characteristics will guide actions for clinician retraining, software modification, and the need for additional guidance and policies.
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. Maintenance Activities Maintenance begins after implementation when activities are carried out to keep a system operational and to support ongoing use.
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108 TABLE 4-6 Measure Concepts for Successful Implementation I II III IV V Planning and Goal Setting Deployment Stabilization Optimization Transformation – IT, medical, and – Percentage of time – Ongoing health IT – Show improved – System up operations leaders system is available patient safety with outcomes over time – Percentage of users identified and in agree- analysis of reporting – User proficiency – Health care is safer trained ment on objectives and remediation of measures based on identified – Percentage of users safety issue – Teams identified measures – Trend of errors logged in – Tracking of quality – Money and resources identified in the field – Care processes – Number and nature measures over time made available per week redesigned of errors identified in – Quality improvement – Alert overrides – Continuous improve the field per week (QI) projects and re- ment of new steady – Event reports – Quality assurance stats sults state for each interface – System passes ongo – Quality assurance user ing safety tests after all acceptance testing upgrades, crashed stats for system or new application implementations – "Shakedown cruise" stats -- review of functionality in initial period post go-live
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From page 109... ...
Advance planning, education, training, and practice for downtime can aid in successful performance during planned or unplanned outages. MINIMIZING RISKS OF HEALTH IT TO PROMOTE SAFER CARE Although not everything is known about the risks of health IT, there is some evidence to suggest there will be failures, design flaws, and user behaviors that thwart safe performance and application of these systems.
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From page 110... ...
can expand product requirements that address safer deployment with strategies to mitigate anticipated risks and address those that develop unexpectedly. Accrediting agencies can reinforce relevant standards and criteria for safer health IT by including review criteria for areas such as training, standardized testing procedures, maintenance, and safety issue reporting and remediation internally and with vendors.
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From page 111... ...
2009. Electronic health record usability: Interface design considerations.
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2010a. Customized common industry format template for electronic health record usability testing.
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From page 113... ...
2009. Designing the user interface: Strategies for effective human-computer interaction.
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