IOM report warns of danger in rushing IT training, as providers, vendors push for keeping safety reporting voluntary
The rush to digitize patient information may produce unintended casualties if hospitals do not invest adequate time, effort and money in training their staffs to correctly use health information technology. And a linchpin of those efforts must be greater participation by clinicians, according to a highly anticipated report on the intersection of IT and patient safety.
The report, issued by a committee of the Institute of Medicine, urged creation of a new agency to investigate deaths, injuries and unsafe conditions associated with health IT, prompting providers and vendors to counter with a call for more aggressive voluntary reporting and thoughtful implementation as the most effective ways to address the concern.
But the federal official who requested the report, Dr. Farzad Mostashari, national coordinator for health information technology, appears inclined to follow the direction of the IOM group. “ONC will lead an HHS planning initiative to develop a comprehensive EHR safety action and surveillance plan well within the 12-month period recommended by IOM,” Mostashari wrote in a blog post about his office's view of the conclusions.
The report emphasized a lack of information to accurately assess the dangers, but concluded from the limited data available that much of the threat comes from the ways providers use IT.
“We kind of like to blame it on the vendors” when there are problems, Lydia Washington, director of practice leadership at the American Health Information Management Association, said. “That's not fair at all; it's got to have both sides involved—the organizations implementing it and the vendors.”
The importance of health IT implementation was highlighted by several examples in the report, including research on the markedly different patient outcomes for pediatric intensive-care units in Pittsburgh and Seattle when they implemented the same electronic health-record system, which included computerized physician order entry. The Pittsburgh unit experienced a significant increase in mortality, while no such increase occurred in the Seattle unit. An additional study found no mortality change or even decreases in mortality at several other children's hospitals that subsequently added the same system.
“The way in which health IT is designed, implemented and used can determine whether it is an effective tool for improving patient safety or a hindrance that threatens patient safety and causes patient harm,” the report stated.
The conclusion that problems frequently stem from providers inadequately understanding or incorrectly using various types of health IT echoed findings from a recent survey. AmericanEHR Partners surveyed 2,338 physicians online this year and determined that those who received at least three to five days of training were the most comfortable with their EHR system. Unfortunately, the survey released in October also found 49.3% of the physicians received three or fewer days of EHR training.
Such findings indicate that some hospitals and other provider groups may not spend enough time, effort and money to implement their health IT systems, according to healthcare experts. Erik Johnson, a senior vice president with consulting firm Avalere Health, said when he has seen health providers slow down their implementations of complex health IT systems it has in turn driven up the cost of the installation of those systems.
“People who have implemented these successfully have gone over budget,” Johnson said. An example of that, he said, was the $4 billion, 10-year development of the largest private-sector EHR by Kaiser Permanente, which it rolled out last year and has since been described as potentially a national model. “They spent that because they wanted to be sure they were doing it right,” he said.
Dr. Paul Tang, one of the report's authors and chief innovation and technology officer at the Palo Alto (Calif.) Medical Foundation, said in an interview that although spending more on implementation does not guarantee improved safety, that is often a benefit of implementing health IT systems well.
“The more your organization has knowledge about the details of that system, the fewer mistakes that will result from their use of it,” Tang said.
That has been the experience of Citizens Memorial Healthcare, in Bolivar, Mo., since it opted to spend more than it initially planned on some aspects of implementation of an EHR to improve the clinical outcomes, said Denni McColm, the hospital's chief information officer. She credited the hospital's successful 2003 EHR implementation to the use of phased-in launches across the different departments in the 76-bed hospital; hiring additional IT staff; and maintaining long-term extra IT assistance for staff that was initially planned as temporary.
Another important component of the hospital's EHR implementation, which echoed the IOM report, was the extensive outreach to the hospital's clinicians before the process began and the agreement of those clinicians to participate in the extensive training needed. “When needed, we were relentless in going after them to receive the training,” McColm said. “We told them we'd show up at their house at midnight if we needed to.”
The hospital also had to learn from a few missteps, McColm acknowledged, including identifying the right type of trainer who could connect with physicians. They tried both nurses and physicians as trainers but ultimately had more success with an administrator.
Those efforts led HIMSS Analytics, the data analysis and consulting arm of the Healthcare Information and Management Systems Society, to recognize Citizens as the first rural hospital to receive the group's Stage 7 Award, given to hospitals that achieve the highest level of EHR adoption and health information exchange capabilities.
Citizens Memorial has continued training its staff on using its commercial EHR system to improve clinical outcomes. In recent years, the hospital has begun coaching clinicians to include patients in the process of adding data to the EHR. That collaboration, intuitively done by some of its clinicians from the launch of its EHR, has demonstrated a number of clinical benefits, such as helping to ensure the data in the EHR is accurate, McColm said.
Similar efforts are under way at hospitals nationwide, said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. So the report's emphasis on careful implementation and thorough training of clinical staff on the use of health IT is less an alert to hospitals than it is a reflection of the approach many hospitals already are taking, she said.
“It is critically important that people be trained and be trained effectively,” Foster said. “That may mean slowing things down a little bit so we can make sure on all shifts with all of those clinicians who interact with it have all of the knowledge that they need to safely use the EHR system.”
One change that hospital advocates hope the report does spur is a delay in the rollout of regulations to implement the federal government's EHR incentive program. Specifically, AHA has asked HHS to slow its issuance of such regulations for the past 18 months, said Chantal Worzala, director of policy at AHA, so hospitals have the time to adequately train their staffs before incentives run out and penalties begin for providers that lack qualifying and well-used EHRs. “We don't want rushed implementation that could risk patient safety,” Worzala said.
Another time-consuming aspect to EHR implementation, Worzala said, is the effort to provide feedback to commercial vendors on what functions well in their system and what needs improvement. Such feedback is critical to improving overall health IT safety, according to the IOM report.
Provider and health IT company advocates said they hoped other efforts of the report have much less regulatory impact. Specifically, they worried about the report's call for the Food and Drug Administration to regulate health IT products for the first time if extensive safety data is not both collected and widely released.
An FDA regulatory regime similar to that used for medical devices and medicines would likely stifle innovation in the rapidly evolving health IT field, said Dr. Edward Fotsch, CEO of PDR Network, the for-profit publisher of the Physicians' Desk Reference, who was consulted by the report's authors. Fotsch said he hopes that the federal government allows enough time for an industry-sponsored voluntary safety-reporting system for health IT to ramp up and produce results before it steps in.
That information collection effort, operated jointly by the Electronic Health Records Association and the iHealth Alliance, launched in early November to expand the data collection capacity and distribution ability of ehrevent.org over the coming year, said Dr. Nancy Dickey, chair of the iHA. It is an expansion of the site, which has collected data on medical incidents possibly related to the use of health IT for nearly a year. “This will try to demonstrate the effectiveness of a nonregulatory, voluntary program,” she said.
A formal federal role in collecting quality data would likely suppress patient-safety reporting from providers and vendors, because of concerns about the consequences of those reports, Fotsch said. “That could have a very chilling effect.”