Institute of Medicine Report on HIT

Originally posted 11-9-2011:
The Institute of Medicine (IOM) issued a report yesterday around the safety issues with Healthcare Information Technology (HIT). The report, titled "Health IT and Patient Safety: Building Safer Systems for Better Care" was released by the same organization that released the "To Err is Human" report which triggered the Patient Safety initiatives of the past decade. I knew this report was in the works, and am glad to have seen it finally come to light.   I have not had a chance to read through the report yet, but there is a good summary that hits on the key points of the report.

Plain and simple, the report covers the growing number of reports of patient harm caused by HIT systems. Combine that with the Meaningful Use incentives, I think the concerns raised in the report are valid. Studies have shown that HIT systems can promote better patient outcomes, but there have been clearly documented side effects. The problem is, there are no standards or regulations to encourage safer software. There is not a mandatory reporting system, like the FDA has for medical devices. I have said this before, but how can healthcare leaders learn from mistakes without understanding where the healthcare system broke down?

I am glad to see the report is making a recommendation that there needs to be reporting of safety breakdowns of these systems. I am also happy to see that the group feels there needs to be an organization overseeing HIT with an eye toward safety. I wonder if the FDA would be the appropriate group, and we should consider HIT as a medical device. The FDA isn't perfect, but I would imagine expanding the FDA would be easier than creating an entirely new government organization.

I was also glad to hear the report say that “poor user interface design, poor workflow, and complex data interfaces are threats to patient safety". User Centered Design (UCD) techniques are clearly needed to address these concerns. And I'm not just saying that to push my own job security. The work and research have been done to show that UCD will help improve the usability, and ultimately, the safety of these systems.

I have said before, I don't want the FDA or other government agency dictating my designs. But I am on board with there being regulations to ensure HIT systems are usable, safe, and meet their purpose of improving patient outcomes.

New Clinical Simulation Center at University of Wisconsin

Originally posted 11-2-2011:
I was pleasantly surprised when I picked up my paper this morning to learn that the University of Wisconsin hospital has opened up a Clinical Simulation Center. I was downright giddy when I realized they had an Open House, which lead me to jump in my car and drive down the road see the center for myself.

I have written before about similar Simulation centers and the importance of simulation in healthcare. In fact, I found real inspiration and understanding for Patient Safety due to an eye opening simulation experience. As a Patient Safety advocate and User Experience designer, how can I not be a fan of healthcare simulation?

I'll admit, I felt like a kid in a candy store at the Open House today. UW has built an impressive center for clinical educational opportunities: They have various types of patient simulator mannequins, including infant and pediatric patients, three simulator rooms for OR, ICU, or regular floor clinical situations, control rooms with cameras for observation, and all of the top of the line equipment you would find if it were the real deal. The people I met there were great, and all understood the importance and significance of the center.

The University of Wisconsin Hospital is doing it right. They are investing their money wisely. I've said it before - would a new pilot jump into the cockpit of a 737 and fly 100 plus people without any training? No, they practice on flight simulators in a safe environment. So why wouldn't we expect the clinicians that take care of our family and ourselves to not do the same? I'm glad to see that UW has gotten on board with this trend. I wouldn't be surprised if most large hospital had facilities like this 10 years from now.

Tomorrow's newspaper will probably not be as exciting...

Coaches in Healthcare

Originally posted 10-5-2011:
I don't make it a secret that Atul Gawande is one of my favorite writers in the world of Healthcare. Once again I have found his latest New Yorker article very intriguing and insightful.

Gawande writes about the importance of coaches, especially around how the world's best athletes have coaches to push them to be better. But he wonders if there is a need for coaches in Healthcare. Here is a world that is full of highly intelligent, well trained, specialized professionals. Do physicians and nurses really need coaches? Can patients accept that care givers should have coaches? It would be a challenge...and Gawande sums it up well by saying:

  • "I have spoken to other surgeons about the idea. “Oh, I can think of a few people who could use some coaching” has been a common reaction. Not many say, “Man, could I use a coach!” Once, I wouldn’t have, either."

Gawande's story of having an old mentor come observe his surgeries to coach him on improving his technique was very interesting to read. There must be something to the concept if he felt his surgeries were running smoother and his complication rates were decreasing. Looking at the sports analogy, even the best athletes have coaches that can make their game even better.  It would be a big cultural barrier to overcome, but I hope others take a close look at this article. This may be one of those outside the box ideas that can really have an impact on patient outcomes.

There was one other line I had to highlight:

  • "Talk about medical progress, and people think about technology...But the capabilities of doctors matter every bit as much as the technology. This is true of all professions. What ultimately makes the difference is how well people use technology. We have devoted disastrously little attention to fostering those abilities."
Given the increased use of technology and the increasing specialization of medicine, I have to imagine care givers will need additional education and training, beyond today's traditional methods, to be effective. Makes me wonder if Gawande is about to set another trend...

Healthcare Technology Limitations

Originally posted 9-16-2011:
I think the push to move healthcare to become less paper based to more electronic systems is a positive one. I believe it allows clinicians to gather and view data to make quicker clinical decisions. With increased interoperability, the continuity of patient care will improve. And electronic systems can store data in a way to identify different health trends sooner than could be done sorting through paper. All of this helps improve safety and patient outcomes.

But technology cannot be treated as a silver bullet make healthcare safer. This blog post does an nice job of summarize how technology can actually cause harm. The post references an LA Times article from the early summer about an infant that received an accidental overdose of Sodium Chloride. The article goes on to highlight other situations where a patient was harmed due to a technology problem. Dr. Kaushal's quote in the article really caught my attention: "We see problems much more often than we would like because many health information systems are poorly designed and difficult for doctors and nurses to use.”

One thing we need to remember is technology is just part of the healthcare work system. Clinicians do not and cannot work in a vacuum with technology. I have said this a few times, but healthcare technology needs to fit into the system in a way to avoid patient harm. One key is to have well designed and well implemented technology to fit into the system to avoid errors.

This is why I was excited to see the EMR Usability Guidelines floating around this summer. The emphasis on well designed healthcare software continues to grow.  Improved usability will not solve all of the Patient Safety problems, but it will be an an important piece of the bigger puzzle for better patient outcomes.

Going public with medical errors

Originally posted 8-26-2011:
I came across an article highlighting three doctors that went public with their medical errors. It gives a view into the minds of doctors and what they go through when they realize they have made an error. The focus is on protecting the "second victims" and how the healing process starts with admitting the errors.

It's great to see that these doctors understood the importance of sharing their stories. Every error made has a lesson behind it that the medical community can learn from. The question should not be around punishing the clinician, but should be focused on how to prevent that same error from happening again. Hiding an error or pretending it didn't happen only allows for a repeat mistake.

I really liked Dr. Bledsoe's quote, "Physicians are human. For anyone to expect absolute perfection in everything is a fool's errand."  This is the essence of Patient Safety science. As you read the article and the shared stories, ask yourself how the errors could have been prevented. How could the system be improved to catch these errors from reaching the patient?

I would rather fly...

Originally posted 7-31-2011:
I would rather:

  • Wait in long security lines
  • Be delayed hours in a strange airport
  • Allow a TSA agent to get a little too friendly with me
  • Lose and be without my luggage for days
  • Be stuck on a sweltering plane for hours waiting for a storm to pass
  • Sleep on the floor of an airport waiting for the next flight
  • Find out my saved miles doesn't apply for my desired flight
  • Eat whatever the heck I just paid $10 for while flying
than have to spend time as a patient in a hospital. Why? Because even though it's a pain, flying is still safer than a hospital stay.

If Air Travel Worked Like Health Care

Originally posted 7-13-2011:
I wanted to share this interesting video that was sent to me this week. It's titled "If Air Travel Worked Like Health Care", and is based on an article by Jonathan Rausch from a couple years ago.

It is very critical of many aspects of the current state of healthcare. From a Patient Safety standpoint, a couple lines stood out to me:
  • "But 95 percent of these questions are always the same. Don't you know that every time I fill out one of these duplicative forms I increase the chance of error? Wouldn't it make more sense to hold my travel information centrally, so that everyone could see the same thing?"
  • "In a sane system, I would call an airline and it would give me a price for the whole trip, not just for one part of it. It would sell me a safe round-trip journey, instead a series of separate procedures."

Protecting yourself and Simulation Medical Centers

Originally posted 6-29-2011:
The June issue of Men's Health had a nice article around ways to protect yourself, as a patient, from potential medical errors. The article provides some easy to follow checklists and questions a patient should be asking themselves to help ensure their safety in the hospital. Common patient scenarios like having surgery, requiring an IV, and having a baby are covered with tips for a patient or patient advocate. This is the type of patient education needed to make sure patient's are included in the feedback loop to ensure their own positive outcomes.

What really got my attention as I read the article is where the author went to research his piece. He traveled to the Banner Simulation Medical Center in Arizona to "play doctor" for a couple days to help identify potential opportunities for error in the healthcare setting. As someone who has struggled through medical simulation, I thought it was great idea to support the tips provided in the article.

I applaud Banner for supporting such a large facility for Medical Simulation. The virtual hospital can train up to 1875 nurses in a safe environment to practice for real patients, and is one of the largest of it's type in the world. I feel this is a growing trend that will change the way caregivers are trained in medicine. The best way to sum up the importance of simulation is stated in the Men's Health article: "If they make a mistake, we just reboot the patient."  But instead of listing off the benefits again, I would recommend watching this video to hear it directly from the people that are undergoing training there.

If only "rebooting" the patient was just that easy...

Update on EMR Usability Guidelines

Originally posted 6-21-2011:
I have noticed there has been a lot of articles written around EMR and Health IT usability in the last couple months. This is due to the National Institute of Standards and Technology (NIST) and the Office of the National Coordinator for Health Information Technology (ONC) combining to develop "a set of procedures that are objective and repeatable for evaluating, testing and validating the us...  A couple weeks ago NIST held an informational hearing and workshop to present their framework and guidelines for healthcare software usability.

There has been some concern expressed that the guidelines could go too far in standardizing EMRs. Those concerns are understandable. I would not want a governing body creating standards as to what the best designs are to promote usability in healthcare software.  Instead, it appears "The goal is to help systems developers and vendors assess and demonstrate that their software is free from design-induced user error. But NIST "will not dictate particular user interface designs.” This article suggests that these guidelines may become "Usability Criteria" for the Stage 2 Meaningful Use regulations, and the NIST is focusing "on EHR usability for the improvement of patient safety."  Even HIMSS has been exploring this with an EHR Usability task force, that has been publishing some nice papers on measuring and evaluating usability.

From what I have been reading, this reminds much of the FDA's Human Factors program which requires medical device manufacturer's to show they have followed Human Factors principles. This includes creating requirements that promote patient safety, and testing the devices to ensure they meet those requirements. During audits, the FDA will check to see if a manufacturer include Human Factors as part of the development process.

If this is indeed the case, then this will be a big win for Patient Safety.   It has been well documented that poor usability in the healthcare software can lead to errors that can potentially harm patients. With all the distractions and time pressures care givers deal with, technology should be a tool that works for them, not against them. Care givers will have less frustrations in their day to day work, which will allow them to focus more on the patients. A happier, less distracted care giver will make better decisions - leading to better outcomes for the patients. Ultimately, this is what really matters in healthcare.