About the Webinar The federal government has spent tens of billions of dollars getting providers to install EHR systems-all in the hopes of making care more efficient, safe and cost-effective. But EHRs can introduce their own safety risks, whether from confusing displays, excessive alerts or a range of other factors. This hourlong webinar will explore where we are now on health IT-related safety and what you can do to mitigate hazards in your own organization. You can learn more about this event: http://www.modernhealthcare.com/article/20150908/WEBINAR/309099998/webinar-ehr-safety-identifying-and-mitigating-health-it-related-risks

1. WEBINAR WELCOME!
Raj Ratwani
Scientific director, National
Center for Human Factors
in Healthcare, MedStar
Institute for Innovation
Dr. Hardeep Singh
Chief of the health policy, quality
and informatics program,
Michael E. DeBakey
VA Medical Center and
Baylor College of Medicine
Joseph Conn
Moderator
Health information
technology reporter
Modern Healthcare
During today’s discussion, feel free to submit
questions at any time by using the questions box.
A follow-up e-mail will be sent to all attendees
with links to the presentation materials online.
Dr. Andy Gettinger
Chief medical information
officer and acting director,
Office of Clinical Quality and
Safety, ONC
Panelists:
EHR SAFETY: Identifying and mitigating health IT-related risks

2. WEBINAR HOUSEKEEPING

3. NOW SPEAKING
Please use the questions box on your webinar
dashboard to submit questions to our moderator
WEBINAR
EHR SAFETY: Identifying and mitigating
health IT-related risks
Joseph Conn
Moderator
Health information
technology reporter
Modern Healthcare

4. NOW SPEAKING
Please use the questions box on your webinar
dashboard to submit questions to our moderator
WEBINAR
EHR SAFETY: Identifying and mitigating
health IT-related risks
Dr. Andy Gettinger
Chief medical information officer
and acting director,
Office of Clinical Quality and Safety,
ONC

5. ONC: EHR Usability
9/21/2015
Office of the National Coordinator for
Health Information Technology
0

6. • Focus on patient-centered
cognitive support for clinicians
• Short-term research that
addresses usability and
workflow
• Long-term research that can
remove key cognitive barriers
to HIT adoption and
meaningful use
9/21/2015
Office of the National Coordinator for
Health Information Technology
1
http://inspiredehrs.org

7. 9/21/2015
Office of the National Coordinator for
Health Information Technology
2

8. • Nothing has been
approved at HHS or
Congress
• Seed money from HHS
• Public private
partnership
• Protected space for
work protected from
litigation
Safety Center is NOT
• A bricks and mortar
physical entity
• Federal entity collecting
data
9/21/2015
Office of the National Coordinator for
Health Information Technology
3

9. ONC Current Activity
in Usability
9/21/2015
Office of the National Coordinator for
Health Information Technology
4

10. Thank You
Contact Information
andrew.gettinger@hhs.gov
www.healthit.gov
5

11. NOW SPEAKING
Please use the questions box on your webinar
dashboard to submit questions to our moderator
WEBINAR
EHR SAFETY: Identifying and mitigating
health IT-related risks
Dr. Hardeep Singh
Chief of the health policy, quality and
informatics program
Michael E. DeBakey VA Medical
Center and Baylor College of Medicine

12. DEFINING AND MEASURING THE
INTERSECTION OF HEALTH IT
AND PATIENT SAFETY
HARDEEP SINGH, MD, MPH
HOUSTON VETERANS AFFAIRS CENTER FOR INNOVATIONS IN
QUALITY, EFFECTIVENESS & SAFETY
MICHAEL E. DEBAKEY VA MEDICAL CENTER
BAYLOR COLLEGE OF MEDICINE
1

13. 2

14. Safety Begins with Measurement
We cannot improve what we cannot
measure!
We cannot measure what we cannot
define!
3

15. 8-dimensional Socio-Technical Model of
Safe & Effective Health IT Use
4
Sittig Singh QSHC 2010

16. Health IT Safety Hierarchy – 3 Phases
5
Phase 1: Safe health IT:
Events unique/specific to health IT
Sittig & Singh N Engl J Med. 2012 Nov 8;367(19):1854-60

17. 6

18. Health IT Safety Hierarchy– 3 Phases
7
Phase 1: Safe health IT:
Events unique/specific to health IT
Phase 2: Using health IT safely:
Unsafe or inappropriate use of technology
Unsafe changes in the workflows that
emerge from technology use
Sittig & Singh N Engl J Med. 2012 Nov 8;367(19):1854-60

20. 9

21. Health IT Safety Hierarchy – 3 Phases
10
Phase 1: Safe health IT :
Events unique/specific to EHRs
Phase 2: Using health IT safely:
Unsafe or inappropriate use of technology
Unsafe changes in the workflows that emerge from
technology use
Phase 3: Using health IT to improve safety
Leveraging health IT to identify unsafe care processes
and potential patient safety concerns before harm
Sittig & Singh N Engl J Med. 2012 Nov 8;367(19):1854-60

23. Singh Sittig BMJ Qual Saf doi:10.1136/bmjqs-2015-004486

24. Which HIT-related Safety Concerns to
Measure?
13
Type of HIT-related safety concern Examples
1. Instances in which HIT fails during use or is
otherwise not working as designed.
Broken hardware
or software “bugs”
2. Instances in which HIT is working as designed,
but the design does not meet the user’s
needs or expectations.
Usability issues
3. Instances in which HIT is well-designed and
working correctly, but was not configured,
implemented, or used in a way anticipated
or planned for by system designers and
developers
Duplicate order
alerts that fire on
alternative PRN
pain medications
Sittig Classen Singh J Am Med Inform Assoc. 2014 Oct 20

25. Which HIT-related Safety Concerns to
Measure?
14
Type of HIT-related safety concern Examples
4. Instances in which HIT is working as designed,
and was configured and used correctly, but
interacts with external systems (e.g., via
hardware or software interfaces) so that
data is lost or incorrectly transmitted or
displayed.
Medication order for extended
release morphine inadvertently
changed to immediate release
morphine by error in interface
translation table
5. Instances in which specific safety features or
functions were not implemented or not
available (i.e., HIT could have prevented a
safety concern).
Hospitalized patient
inadvertently receives 5 grams
of acetaminophen in 24 hours
because maximum daily dose
alerting was not available
Sittig Classen Singh J Am Med Inform Assoc. 2014 Oct 20

26. Proactive Measurement
ONC-sponsored “Safety Assurance Factors for
EHR Resilience (SAFER) project”
Proactive risk assessment and guidance
“1st draft” of best practices and knowledge
Self-assessment; not meant to be regulatory
Focused on high-risk areas
Nine guides—all freely available
Singh et al BMC Med Inf 2013
15
http://www.healthit.gov/safer

27. Foundational Guides
High Priority Practices
Organizational Responsibilities
Infrastructure Guides
System Configuration
System Interfaces
Contingency Planning
Clinical Process Guides
Patient Identification
Computerized Provider Order Entry with CDS
Test Results Reporting and Follow-up
Clinician Communication
SAFER: Safety Assurance Factors for EHR Resilience
Sittig, Singh, Ash. Am J Manag Care. 2014;20(5):418-423
16
http://www.healthit.gov/safer

28. SAFER Recommended Practices
17

31. Take Home
20
Essential to have robust definitions &
measurement approaches
Certain risk areas are now well defined
and amenable to local measurement for
QI/safety purposes
Measuring health IT-related safety needs
to become an essential component of
overall patient safety strategy

32. Thank you…
21
Funding Agencies
Department of Veterans Affairs
Agency for Health Care Research & Quality
National Institute of Health
Office of National Coordinator (SAFER Guides)
Multidisciplinary team at Houston-based
VA Health Services Research Center of Innovation
Contact Information…
Hardeep Singh, MD, MPH
hardeeps@bcm.edu
@HardeepSinghMD

33. NOW SPEAKING
WEBINAR
EHR SAFETY: Identifying and mitigating
health IT-related risks
Please use the questions box on your webinar
dashboard to submit questions to our moderator
Raj Ratwani
Scientific director
National Center for
Human Factors in Healthcare,
MedStar Institute for Innovation

34. Health IT Usability, Clinician
Workflow, and Safety Hazard
Identification
Raj Ratwani, PhD
Scientific Director
National Center for Human Factors in Healthcare,
MedStar Health
Assistant Professor of Emergency Medicine,
Georgetown University

35. 1: User Interface Design
Displays and Controls
Screen Design
Clicks & Drags
Colors & Navigation
The Two Bins of Usability
2: Cognitive Task Support
“Workflow Design”
Smart Data Visualization
Support Cognitive Work
Functionality
Photo credit to Bob Wears, MD, PhD

36. EHR Usability
• Many vendors are not employing rigorous User-
centered design processes
• Safety enhanced design reports demonstrate:
– Many vendors are not adhering to
requirements
– Testing standards are violated
• What is the frontline impact?
Ratwani, R.M., Benda, N., Hettinger, A.Z., & Fairbanks, R.J. (2015) Electronic Health Record Vendor Adherence to Usability
Certification Requirements and Testing Standards. Journal of the American Medical Association (JAMA) 314(10):1070-1071.
Ratwani, R.M., Fairbanks, R.J., Hettinger, A.Z. & Benda, N. (2015). Electronic Health Record Usability: Analysis of the User Centered
Design Processes of Eleven Electronic Health Record Vendors. Journal of the American Medical Informatics Association.

37. Frontline Impact
• How does use of a new EHR with CPOE
impact physician performance in the ED?
– Three study periods: pre, go-live, post
– 2 hour observation periods
– 14 EM physicians during each phase
• Observers record minute by minute
allocation to different tasks
– Computer, verbal communication, patient
time, paper
Benda, N., Meadors, MA, Hettinger, A.Z, and Ratwani, R.M. (in
press). Emergency Physician Task Switching Increases with the
Introduction of a Commercial EHR. Annals of Emergency Medicine

38. Task Allocation Time
Benda, N., Meadors, MA, Hettinger, A.Z, and Ratwani, R.M. (in
press). Emergency Physician Task Switching Increases with the
Introduction of a Commercial EHR. Annals of Emergency Medicine

39. Tasks Per Minute
Benda, N., Meadors, MA, Hettinger, A.Z, and Ratwani, R.M. (in
press). Emergency Physician Task Switching Increases with the
Introduction of a Commercial EHR. Annals of Emergency Medicine

40. Significant Increase in Task
Switching
• The cognitive cost of the EHR is increased
task switching:
– Increased stress and frustration
– Increase likelihood of error
• Users are forced to adapt their work
practices to the EHR
Benda, N., Meadors, MA, Hettinger, A.Z, and Ratwani, R.M. (in
press). Emergency Physician Task Switching Increases with the
Introduction of a Commercial EHR. Annals of Emergency Medicine

41. Strategies for Identifying Safety
Hazards
• Observation and analysis in highest risk
clinical environments
– Task tracking, visualization and analysis
• Leveraging event reporting systems and
help desk data
– Visualization and natural language processing
Fong, A. & Ratwani, R.M. (2015). An Evaluation of Patient
Safety Event Report Categories Using Unsupervised Topic
Modeling. Methods of Information in Medicine. 54 (3).

42. Task Tracker

43. Workflow Visual Analytics Tool

44. Data Analytics
• Identify health IT related safety events
from adverse event data
– Visualization and natural language processing
techniques
• Examining “help desk” data to identify
patterns and trends

45. Thank you
Raj Ratwani, PhD
Raj.Ratwani@MedicalHFE.org
@RajRatwani

46. WEBINAR
TODAY’S PANELISTS
EHR SAFETY: Identifying and mitigating
health IT-related risks
During today’s discussion, feel free to submit questions at any time by using the questions box
Raj Ratwani
Scientific director, National
Center for Human Factors
in Healthcare, MedStar
Institute for Innovation
Dr. Hardeep Singh
Chief of the health policy,
quality and informatics program,
Michael E. DeBakey
VA Medical Center and
Baylor College of Medicine
Joseph Conn
Moderator
Health information
technology reporter
Modern Healthcare
Dr. Andy Gettinger
Chief medical information
officer and acting director,
Office of Clinical Quality and
Safety, ONC

47. Expect a follow-up email within two weeks
with links to presentation materials and
information about how to offer feedback.
For more information about
upcoming webinars, please visit
ModernHealthcare.com/webinars
WEBINAR THANK YOU FOR ATTENDING
Thanks also to our panelists:
EHR SAFETY: Identifying and mitigating health IT-related risks
Raj Ratwani
Scientific director, National
Center for Human Factors
in Healthcare, MedStar
Institute for Innovation
Dr. Hardeep Singh
Chief of the health policy, quality
and informatics program, Michael
E. DeBakey VA Medical Center and
Baylor College of Medicine
Joseph Conn
Moderator
Health information
technology reporter
Modern Healthcare
Dr. Andy Gettinger
Chief medical information
officer, acting director,
Office of Clinical Quality
and Safety, ONC