Healthcare providers struggle to address patient safety issues created by their EHRs and other health IT infrastructure, says a new report by the RAND Corporation and funded by the ONC. With “limited” awareness of the dangers presented by poor workflows or technical errors and widespread difficulty summoning up resources and creating engagement among staff to tackle safety risks, providers are unlikely to make significant changes to their habits unless the errors impact financial reimbursement or an outside facilitator urges them to improve.
In conjunction with the University of Texas, ECRI Institute, and Baylor College of Medicine, RAND designed a pilot program intended to explore the challenges of identifying and mitigating the risks involved in health IT adoption. Using a standardized assessment, the pilot both flagged areas of concern and offered assistance to rectify them while evaluating the governance and change management strategies used within the organization. Eleven ambulatory and hospital providers, geographically diverse and covering a range of sizes, types, and levels of health IT adoption, agreed to participate in the nine-month program.
“Most of the participating organizations found it difficult to identify and modify health IT safety risks within the nine-month project period, even with the resources and technical assistance available,” the report says. Providers selected a specific area of focus, such as clinical communication or CPOE to address during the pilot, but “even though several organizations narrowed the focus of their projects, they encountered significant barriers at every stage of the process.”
While organizations with a pre-existing culture of quality improvement were most likely to succeed in the venture, the majority of participants were more likely to focus on previously identified issues rather than those problems uncovered by the RAND assessment. Issues related to meaningful use participation were of a high priority, as were patient safety risks that aligned with existing strategic goals, such as enrolling in value-based reimbursement structures. “Organizations tended to view health IT safety through the lens of their efforts to meet MU standards,” the study notes.
“Organizations tended to view health IT as a solution to patient safety problems, while overlooking the potential of health IT to contribute to safety problems or to create new types of safety risks,” the study said. “Organizations installing, expanding, or upgrading EHRs are focused on ensuring that systems are operational and support necessary functions and that staff have sufficient training to use EHRs meaningfully. While these concerns clearly have implications for patient safety, the new safety risks associated with the implementation and use of health IT, especially EHRs, were not perceived in general as requiring focused effort.”
Staff members also complained that the AHRQ Common Formats used for reporting patient safety risks were cumbersome and time-consuming, indicating the need for more intuitive tools to ease reporting and encourage staff members to collect accurate and useful data on patient risks.
Just as with EHR implementation, optimizing health IT infrastructure to minimize patient safety risks relies on strong leadership and organizational buy-in. Staff members engaged in the project often had to divert time and resources away from competing projects, such as meaningful use or the ICD-10 transition, and the perceived conflict often led to poor project design. Providers expressed interest in the use of outside facilitators to aid the process, but the ability of executive leaders to recognize and prioritize safety improvement efforts – and allocate resources to sufficiently deal with the issues – within the organization was a key determinate of success.
“Health IT risks are sociotechnical in nature. They involve individuals conducting highly complex workflows that interact with complex technologies. This is an inherently challenging analytic problem,” the report concludes. “To raise awareness of the health IT safety issue, two steps are necessary and closely related: to integrate and align the health IT safety agenda with the broader patient safety agenda and to engage front line clinicians in identifying and mitigating risk. There may also be a need for additional tools and metrics (and further usability study of existing tools and metrics) to better support the needs of health care organizations as they use health IT to improve the quality and safety of patient care.”