The Opportunity
Implementation and adoption of health information technology (HIT) is widely viewed as essential to the transformation of health care, and a key to satisfying the diverse needs of stakeholders burdened by rising costs, inefficiency, preventable errors, and poor quality of care. Since the creation of the Office of the National Coordinator for Health Information Technology (ONC) in 2004, over $24 billion has been spent in economic incentives for eligible health care providers to adopt and meaningfully use certified EHR technology.1 While the use of HIT presents many new opportunities to improve patient care and safety, it can also create new hazards, and will fulfill its potential only if the risks associated with its use are identified and a coordinated effort is developed to mitigate those risks, as envisioned by the ONC Patient Safety Action and Surveillance Plan.2
An HIT-related safety event—sometimes called “e-iatrogenesis”—has been defined as “patient harm caused at least in part by the application of health information technology.”3 Detecting and preventing HIT-related safety events is challenging because these are often multifaceted events, involving not only potentially unsafe technological features of electronic health records, for example, but also user behaviors, organizational characteristics, and rules and regulations that guide most technology-focused activities. HIT-related error has been described as occurring “anytime the HIT system is unavailable for use, malfunctions during use, is used incorrectly, or when HIT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted.”4 Assessing and addressing the complexities associated with patient safety and HIT is likely to require comprehensive and newer ‘sociotechnical’ approaches that account for these multiple dimensions.5
Increasing public awareness of HIT-related safety concerns, including greater media attention, has raised this issue’s profile and added urgency to efforts to assess the scope and nature of the problem and to develop potential solutions. The 2012 Food and Drug Administration Safety Innovation Act (FDASIA) required coordinated activity between the FDA, ONC, and the Federal Communications Commission (FCC) on a strategy to develop a regulatory framework for HIT that promotes patient safety, among other goals. These agencies’ subsequent work and the HIT Policy Committee’s recent recommendation to create a public-private Health IT Safety Center have underscored the importance of partnerships, collaboration, and shared responsibility in ensuring the safe use of HIT. Given the variety of groups that that affect and are affected by HIT-related safety issues, successful efforts to improve the safety of HIT will depend on the involvement and cooperation of multiple stakeholders.
About the Project
This project, which launched in September 2014, will assess the current environment related to measurement of HIT-related safety events and construct a framework for effective mitigation of risk and advancement of measurement to improve the safety of HIT.
This project will be guided by a multi-stakeholder NQF Committee which includes experts in health information technology data systems and electronic health records, providers across different settings, front-line clinicians, public and private payers, and experts in patient safety issues related to the use of HIT. The Committee will work to explore the intersection of HIT and patient safety in order to create a report that will provide a comprehensive framework for assessment of HIT safety measurement efforts, a measure gap analysis and recommendations for gap-filling, and best practices and challenges in measurement of HIT safety issues to-date. The Committee will use relevant elements of NQF's Consensus Development Process to ensure transparency and public input. However, as this project will not include the review and assessment of consensus standards, it will not include a member voting period.
Funding
This project is funded under NQF’s contract with the Department of Health and Human Services, “National Strategy and Priorities for Healthcare Performance Measurement.”
For information about the availability of auxiliary aids and services for NQF’s federally funded projects, please visit: http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html.
Related NQF Work
Contact Information
For more information, please contact Ann Phillips at 202-783-1300 or via email at SafetyandHIT@qualityforum.org.
Notes
1 Manos, D. EHR incentive payments climb towards 24 billion. Government Health IT. June 2014: Retrieved from http://www.govhealthit.com/news/ehr-incentive-payments-near-24-billion.
2 The Office of the National Coordinator for Health Information Technology. 2013. Health Information Technology Patient Safety Action & Surveillance Plan. Retrieved from http://www.healthit.gov/sites/default/files/safety_plan_master.pdf
3 Weiner JP, et al. 2007. “E-iatrogenesis”: The most critical unintended consequence of CPOE and other HIT. Journal of the American Medical Informatics Association 14(3):387-388.
4 Sittig DF, Singh H. Defining Health Information Technology-related Errors: New Developments Since To Err Is Human. Arch Intern Med. 2011;171(14):1281-1284.
5 Sittig DF, Singh H. A New Socio-technical Model for Studying Health Information Technology in Complex Adaptive Healthcare Systems. Qual Saf Health Care. Oct 2010; 19 (Suppl 3): i68-i74.