According to the report, potential health IT patient safety risks could relate to IT design, use, or implementation. Examples of risks could include design flaws that can result in the recording of inaccurate patient information, alert fatigue (where clinicians receive such a high volume of alerts that they begin to ignore them), and flawed implementation strategies that may result in clinicians circumventing IT safety features.

“Identifying patient safety risks associated with use of health IT is foundational to reap the benefits of IT to improve patient care, and all healthcare and health IT stakeholders have a shared responsibility to address these risks,” said Hardeep Singh, MD, MPH, chief of the Health Policy, Quality & Informatics Program at the Center for Innovations in Quality, Effectiveness, and Safety based at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston. “Our recommendations prioritize risk areas and build a strong scientific foundation to advance measurement and improvement of patient safety in this area.”

Singh co-chaired a multistakeholder Committee of 22 health IT and safety experts convened by NQF for this project.

The Committee recommended that measures to address the patient safety associated with the use of health IT consider these high-level concepts:

• Safe health IT – to ensure that health IT is accessible and usable on demand by all members of a care team and that health IT data are complete, accurate, secure, and protected
• Using health IT safely – to ensure that  features and functionality are effective, efficient, and implemented as intended; that there are structures, processes, and procedures in place to ensure safety and safe use of health IT; and that there are effective mechanisms to monitor, detect, and report on the safety and safe use of health IT
• Improving patient safety – to ensure that health IT is leveraged to reduce patient harm and improve the safety of patient care and enables meaningful and effective patient engagement.

The Committee also recommended that measurement of health IT safety prioritize addressing the safety of tools that help clinicians make decisions about patient care (clinical decision support, or CDS) as well as the ability of health IT systems to exchange information (interoperability).

CDS provides clinicians with guidance in making critical decisions at the point of care. But poorly designed or configured CDS can threaten patient safety, such as when clinicians experience alert fatigue. The Committee recommends that CDS measurement address the appropriateness and timing of alerts, the appropriateness of clinicians’ responses to those alerts, and the monitoring of CDS content to ensure that it remains useful, clinically relevant, up-to-date, and free of errors.

Meanwhile, as healthcare is frequently delivered and managed by multiple providers at different locations, the ability of health IT systems to seamlessly exchange patient data is increasingly important. But many EHRs still are not interoperable, potentially leading to failures in communicating important patient information (such as test results) and delays in treatment. The report suggests that measurement of interoperability could assess whether systems have the ability to communicate and exchange specific types of data and how often diagnostic test results are unavailable when needed.

“With the rapid adoption of health IT across the continuum of care, we must consider the potential impact on patient safety to ensure that this critically important tool is a positive and transformational force for change,” said Helen Burstin, MD, MPH, chief scientific officer of NQF.