Evolution of Health Information Technology and Patient Safety in the U.S.

History of Health Information Technology in the U.S. History of Quality Improvement and Patient Safety

History of Quality Improvement and Patient Safety Learning Objectives Describe conditions and notable publications concerning patient safety and quality improvement from 1959 to the present Describe the background to the Institute of Medicine reports on patient safety Summarize the main findings from several Institute of Medicine reports on quality, patient safety, and health information technology (HIT) Describe various ways in which HIT has evolved to improve quality or enhance patient safety 2

Institute of Medicine Reports 1999 3

Institute of Medicine Reports 2 Medical errors kill up to 98,000 people annually Errors result from a faulty system not faulty individuals 4

Institute of Medicine Reports 3 Quality of care includes six main components 5

Institute of Medicine Reports 4 Quality of care includes six main components Quality is suboptimal Health IT can help improve quality in many ways 6

History of Patient Safety 460 BC Hippocrates, Greek physician Widely considered the father of western medicine Hippocratic oath: First, do no harm Source: (Wikimedia) 7

History of Patient Safety 2 1959: Diseases of Medical Progress: A Study of Iatrogenic Disease by Robert Moser 8

History of Patient Safety 3 1980s and 90s: Medical errors reported in the popular press 9

History of Patient Safety 4 1990: Human Error by James Reason 10

History of Patient Safety 5 1991: Harvard Medical Practice Studies completed Sources: (Brennan et al., 1991) (Leape et al., 1991) 11

History of Patient Safety 6 1994: Error in Medicine by Lucian Leape published in JAMA 12

History of Patient Safety 7 1999/2001: IOM Reports released 13

History of Patient Safety 8 2000: Leapfrog Group launched 14

History of Patient Safety & Quality 2001: Agency for Healthcare Research and Quality (AHRQ) reorganized by US Congress 15

History of Patient Safety & Quality 2 2002: Joint Commission released National Patient Safety Goals 16

History of Patient Safety & Quality 3 2004: Office of the National Coordinator for Health Information Technology established 17

History of Patient Safety & Quality 4 2009: The HITECH Act 18

2009: The HITECH Act 19

2009: The HITECH Act 2 20

IOM Report 2011 Potential of HIT to create harm Need for better information about the failures of HIT systems Recommendation: Federal government should create new agency to investigate safety of health IT systems 21

Response to 2011 Report Health IT Patient Safety Action and Surveillance Plan SAFER Guides Strategies for safe design and implementation of Health IT FDASIA report Risk-based framework for regulation Sources: (ONC, 2013, ONC 2014, FDA 2014.) 22

Diagnostic Errors Diagnostic errors underemphasized Increased interest beginning with 2008 Diagnostic Error in Medicine conference New IOM report on Diagnostic Errors 2015 Role of HIT Diagnostic Decision Support Systems Diagnosis trigger tools 23

History of Quality Improvement and Patient Safety Summary History of Quality Improvement Patient Safety key milestones 24

History of Quality Improvement and Patient Safety References References Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Studies I.N Eng J Med. 1991; 324(6):370-6. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C: The National Academies Press, 2001. Institute of Medicine. Health IT and patient safety: building safer systems for better care. Washington, D.C: The National Academies Press, 2011. Institute of Medicine. To err is human: building a safer health system. L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, eds. Washington, D.C: The National Academies Press, 1999. Institute of Medicine. Improving Diagnosis in Healthcare. Erin P. Balogh, Bryan T. Miller, and John R. Ball, Eds. Washington, D.C: The National Academies Press, 2015. Leape LL, Brennan TA, Laird NM et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Studies I.N Eng J Med. 1991; 324(6):377-84. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-7. Moser R. Diseases of medical progress: a study of iatrogenic disease. Springfield: C.C. Thomas; 1959. Reason J. Human error. Cambridge: Cambridge University Press;1990.\ Office of the National Coordinator for Health Information Technology. Health Information Technology Patient Safety Action & Surveillance Plan. July 2, 2013. Available from: www.healthit.gov . Accessed May 22, 2016. 25

History of Quality Improvement and Patient Safety References 2 References Office of the National Coordinator for Health Information Technology. SAFER Guides. January 15, 2014. Available from: www.healthit.gov . Accessed May 22, 2016. Food and Drug Administration. FDSASIA Health IT Report. April 2014. Available from: www.fda.gov . Accessed May 22, 2016. Images Slides 3,4: "To Err is Human" book cover, Kohn LT, Corrigan JM and Donaldson MS, (eds). "To Err Is Human: Building a Safer Health System" Committee on Quality of Health Care in America, Institute of Medicine, Washington DC: National Academies Press, 1999. Source Name: Image used with permission from National Academies Press. Slides 5,6: "Crossing Quality Chasm" book cover, Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century, Washington, DC: National Academy Press, 2001. Source Name: Image used with permission from National Academies Press. Slide 7: Bust of Hippocrates, Available from: en.wikipedia.org Source Name: Wikipedia Commons/Courtesy National Library of Medicine Slides 8, 11, 18: Clip Art, Available from: Microsoft clips online Source Name: Used with permission from Microsoft 26

History of Health IT in the US History of Quality Improvement and Patient Safety This material was developed by the University of Alabama at Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0007. 27