Ross Koppel

Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA

In response to mounting evidence that use of electronic medical record systems may cause unintended consequences, and even patient harm, the AMIA Board of Directors convened a Task Force on Usability to examine evidence from the literature and make recommendations. This task force was composed of representatives from both academic settings and vendors of electronic health record (EHR) systems. After a careful review of the literature and of vendor experiences with EHR design and implementation, the task force developed 10 recommendations in four areas: (1) human factors health information technology (IT) research, (2) health IT policy, (3) industry recommendations, and (4) recommendations for the clinician end-user of EHR software. These AMIA recommendations are intended to stimulate informed debate, provide a plan to increase understanding of the impact of usability on the effective use of health IT, and lead to safer and higher quality care with the adoption of useful and usable EHR systems.

Medication Safety in Older Adults: Home‐Based Practice Patterns

Objectives: To identify the current state of medication‐taking practices of community‐dwelling older adults on high‐risk medications.

Health Care Information Technology Vendors' “Hold Harmless” Clause: Implications for Patients and Clinicians

EALTH CARE INFORMATION TECHNOLOGY (HIT) vendors enjoy a contractual and legal structure that renders them virtually liability free—“hold harmless” is the term of art—even when their proprietary products may be implicated in adverse events involving patients. This contractual and legal device shifts liability and remedial burdens to physicians, nurses, hospitals, and clinics, even when these HIT users are strictly following vendor instructions. Vendors avoid liability by relying on the legal doctrine known as “learned intermediaries” and on warranties prohibiting claims against their own products’ fitness. According to this doctrine and legal language, HIT vendors are not responsible for errors their systems introduce in patient treatment, because physicians, nurses, pharmacists, and health care technicians should be able to identify—and correct—any errors generated by software faults. Learned intermediaries are considered medical experts who,througheducation,experience,orboth,areabletobalance the benefits of any medication, dosage, software, or medicaldeviceagainstitspotentialdangers.Thechoicemade

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems

Importance Medication computerised provider order entry (CPOE) has been shown to decrease errors and is being widely adopted. However, CPOE also has potential for introducing or contributing to errors. Objectives The objectives of this study are to (a) analyse medication error reports where CPOE was reported as a ‘contributing cause’ and (b) develop ‘use cases’ based on these reports to test vulnerability of current CPOE systems to these errors. Methods A review of medication errors reported to United States Pharmacopeia MEDMARX reporting system was made, and a taxonomy was developed for CPOE-related errors. For each error we evaluated what went wrong and why and identified potential prevention strategies and recurring error scenarios. These scenarios were then used to test vulnerability of leading CPOE systems, asking typical users to enter these erroneous orders to assess the degree to which these problematic orders could be entered. Results Between 2003 and 2010, 1.04 million medication errors were reported to MEDMARX, of which 63 040 were reported as CPOE related. A review of 10 060 CPOE-related cases was used to derive 101 codes describing what went wrong, 67 codes describing reasons why errors occurred, 73 codes describing potential prevention strategies and 21 codes describing recurring error scenarios. Ability to enter these erroneous order scenarios was tested on 13 CPOE systems at 16 sites. Overall, 298 (79.5%) of the erroneous orders were able to be entered including 100 (28.0%) being ‘easily’ placed, another 101 (28.3%) with only minor workarounds and no warnings. Conclusions and relevance Medication error reports provide valuable information for understanding CPOE-related errors. Reports were useful for developing taxonomy and identifying recurring errors to which current CPOE systems are vulnerable. Enhanced monitoring, reporting and testing of CPOE systems are important to improve CPOE safety.

Identifying and Quantifying Medication Errors: Evaluation of Rapidly Discontinued Medication Orders Submitted to a Computerized Physician Order Entry System

All methods of identifying medication prescribing errors are fraught with inaccuracies and systematic bias. A systematic, efficient, and inexpensive way of measuring and quantifying prescribing errors would be a useful step for reducing them. We ask if rapid discontinuations of prescription-orders--where physicians stop their orders within 2 hours--would be an expedient proxy for prescribing errors? To study this we analyzed CPOE-system medication orders entered and then discontinued within 2 hours. We investigated these phenomena in real time via interviews with corresponding ordering physicians. Each order was also independently reviewed by a clinical pharmacist or physicians. We found that of 114 rapidly discontinued orders by 75 physicians, two-thirds (35 of 53, PPV = 66; 95% CI = 53-77) of medication orders discontinued within 45 minutes were deemed inappropriate (overdose, underdose, etc.). Overall, 55% (63 of 114; 95% CI = 46-64%) of medication orders discontinued within 2 hours were deemed inappropriate. This measure offers a rapid, constant, inexpensive, and objective method to identify medication orders with a high probability of error. It may also serve as a screening and teaching mechanism for physicians-in-training.

Evaluation of Antimicrobial Therapy Orders Circumventing an Antimicrobial Stewardship Program: Investigating the Strategy of “Stealth Dosing”

OBJECTIVE Prior-approval antimicrobial stewardship programs (ASPs) improve patient outcomes and decrease antimicrobial resistance. These benefits would be limited if physicians circumvented ASP efforts. We evaluated whether prescribers wait until after the prior-approval period to order restricted antimicrobial therapy that is in conflict with guidelines or unnecessary. DESIGN A cross-sectional study design and a retrospective cohort study design. SETTING A tertiary care, academic medical center with a prior-approval ASP that was active between 8 am and 10 pm. METHODS We evaluated whether there was an increase in the proportion of orders for antimicrobial therapy that involve restricted (vs nonrestricted) antimicrobials during the first hour that the ASP is inactive (ie, the first hour that prior approval is not required), compared with the remainder of the day. We also evaluated whether restricted antimicrobial therapy ordered during this first hour is less likely to be continued when the ASP becomes active the next day, compared with that ordered during the preceding hour. RESULTS A greater proportion of the antimicrobial therapy orders placed between 10:00 pm and 10:59 pm were for restricted agents, compared with orders placed during other periods (57.0% vs 49.9%; P=.02). Surgical patients for whom antimicrobial therapy orders were placed between 10:00 pm and 10:59 pm were less likely to have that antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 pm and 9:59 pm (60.0% vs 98.1%; P<.001). Nonsurgical patients whose therapy orders were placed between 10:00 pm and 10:59 pm were also less likely to have the ordered antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 pm and 9:59 pm (70.8% vs 84.2%; P=.01). CONCLUSION Physicians avoid having to obtain prior approval for therapy involving restricted antimicrobials by waiting until restrictions are no longer active to place orders. Compared with restricted antimicrobial therapy ordered when the ASP is active, these courses of therapy are less often continued by the ASP, suggesting that they are more likely to be in conflict with guidelines or unnecessary.

Neither panacea nor black box: responding to three journal of biomedical informatics papers on computerized physician order entry systems

a Department of Sociology and Center for Clinical Epidemiology and Biostatistics of the School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA b Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Education and Research in Therapeutics, University of Pennsylvania School of Medicine, USA c Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, USA d Department of Biostatistics and Epidemiology, Department of Medicine (General Medicine Division), Department of Pharmacology, Center for Clinical Epidemiology and Biostatistics, Center for Education and Research in Therapeutics, University of Pennsylvania School of Medicine, USA

Re-examining health IT policy: what will it take to derive value from our investment?

Despite substantial investments in health information technology (HIT), the nations goals of reducing cost and improving outcomes through HIT remain elusive. This period of transition, with new Office of National Coordinator for HIT leadership, upcoming Meaningful Use Stage III definitions, and increasing congressional oversight, is opportune to consider needed course corrections in HIT strategy. This article describes current problems and recommended changes in HIT policy, including approaches to usability, interoperability, and quality measurement. Recommendations refrain from interim measures, such as electronic health record adoption rates, and instead focus on measurable national value to benefit the economy, to reduce healthcare costs, and to improve clinical efficiency and care quality.

Demanding Utility From Health Information Technology

In this issue, DesRoches and colleagues examined physician use of EHR systems to manage their patient populations and their expectations of the influence of EHRs on health care outcomes and costs. ...

First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety

Excerpt] This book is an exploration of why patient safety is advancing at what seems to be an almost glacial pace, despite the often vast and determined efforts of health care workers and managers. A collection of essays from prominent researchers, scholars, and even patients, this book aims to identify some of the gaps in the patient safety movement, the disconnected dots that do not coalesce despite decades of hard work and billions of dollars. It also identifies concerns that have not been integrated into the patient safety discourse or agenda of more established groups.