Safety Task Force June 13, 2014. Task Force Members NameOrganization Members David Bates, chair Brigham and Women’s Hospital & Partners Peggy BinzerAlliance

Safety Task Force

June 13, 2014

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Task Force Members

Name Organization

Members

David Bates, chair Brigham and Women’s Hospital & Partners

Peggy Binzer Alliance for Quality Improvement and Patient Safety

Tejal Gandhi National Patient Safety Organization

Mary Beth Navarra-Sirio McKesson Corporation

Pau Tang Palo Alto Medical Foundation

Toby Samo Allscripts

Steven Stack American Medical Association

Marisa Wilson Johns Hopkins University

Ex-Officio Members

Jodi Daniel ONC

Jeannie Scott Department of Veterans Affairs

Jon White AHRQ

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Meetings

Meetings Task

Thursday, May 299:00-10:00

• Introductory Meeting• Define scope

Monday, June 911:30-1:30

• Review of last meeting and next steps• Questions for input

Friday, Jun 1310:00-12:00

• Presentations• David L. Mayer, NTSB• Bill Munier, AHRQ• Jeanie Scott, VHA• Ronni Solomon, ECRI

Monday, June 239:00-11:00

• EHRA presentation• Prep for final presentation

Monday, July 711:30-1:30

• Final presentation review and wrap-up

Tuesday, July 8 Report to HITPC

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U.S. National Transportation Safety Board (NTSB)

David L. MayerManaging Director

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Agency for Healthcare Research and Quality (AHRQ)

William B Munier, MDDirector, Patient Safety Organization ProgramCenter for Quality Improvement and Patient

Safety

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Veterans Health Administration (VHA)

Jeanie Scott, Director of Informatics Patient SafetyVHA Office of Informatics and Analytics/Health

Informatics

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VETERANS HEALTH ADMINISTRATIONVETERANS HEALTH ADMINISTRATION

MODEL PRESENTATION

HEALTH INFORMATION TECHNOLOGY (HIT) SAFETY: Veterans Health Administration (VHA)

Jeanie Scott, CPHIMSInformatics Patient SafetyHealth InformaticsOffice of Informatics and AnalyticsDepartment of Veterans Affairs

HIT Policy Committee Safety Task Force – Model PresentationJune 13,2014

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Veterans Health Information Systems and Technology Architecture (VistA)

An integrated suite of Health Information Technology Systems used across care settings including:• Electronic Health Record (EHR)• Imaging• Medication Administration• Personal Health Records• Data Sharing with and beyond VHA• Much more – Administrative also…

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History of VA’s EHR

1977 – 1982 – Period of Central Control vs. Decentralized Clinical Innovation1982 – Decentralized development strategy endorsed

1983: 25 sites: outpatient pharmacy, ADT*/scheduling1985: 120 sites: Added lab, inpatient pharmacy, radiology1989: 120 sites: Added eight additional packages

1990 – VistA Imaging1994 – VistA Rad1998 – Computerized Patient Record System (CPRS)2000 – Bar Code Medication Administration (BCMA)2007 – Indian Health Service deploys VistA Imaging

*Admission/Discharge/Transfer (Registration)

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VistA Recognition

More than 30 years experience developing medical IT solutions

• 2011 Harvard University Innovations in American Government Award• 2008 “Top 100” CIO Award• 2011 Toward the Electronic Patient Record (TEPR), 1st place, Personal Health

Record for My HealtheVet – VA’s personal health record• 2010 Government Technology Leadership award for VA’s BCMA program• 2013 Most Wired Award

Built in partnership with clinicians, allied health and health information management professionals key to successful development and adoption.

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VistA

VistA includes many components to deliver high-quality health care to our nation’s Veterans, including:

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• CPRS

• VistA Imaging

• BCMA

• Personal Health Record - My HealtheVet


CPRS

Used throughout the VHA in all health care settings (inpatient, outpatient, long-term care) to deliver an integrated record covering all aspects of patient care and treatment

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Key Features:

• Clinical Decision Support• Documentation• Clinical Reminders• Remote Data Retrieval


BCMA

BCMA virtually eliminates errors at the point of administration

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1994 – VA was one of the first health care organizations to develop BCMA technology to improve patient safety1999 – Deployed to all VA Medical Centers (60,000 beds)2003 – 100% of all VA wards documenting medication administration using BCMA2010 - >2.8 million bar code scans observed since inception


My HealtheVet

A personal My HealtheVet account provides Veterans with 24/7 online access to a variety of tools to manage their health care.

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• Communicate with participating VA Patient Aligned Care Team members

• View VA appointments and health information

• Refill VA prescriptions

• Download and share personal health record via the Blue Button


Evolving….

Commercial Products

Internal DevelopmentMobile

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VA’s HIT Safety Program

The VA’s Informatics Patient Safety Office analyzes HIT–related events/concerns that pose a risk to patient safety

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• Software Development Lifecycle Analysis

• Testing processes

• Deployment strategies

• Implementation practices

• Reporting and analysis of close calls


Identification and Communication

• Medication Ordering errors (LASA) - the software will auto-fill the drug name once three letters are typed. This inserts the first drug on the list with these three letters

• Patient Identification Catastrophic Edits o Modifications to softwareo Procedure guidance ((Internal handbook)

• Alerts/Advisories/Guidance documentso Order Check National Term File Mapping exampleo Deployment strategies

• Mobile Apps – Developing an Inspection Review Process – “Identifying Latent Design Issues in Mobile Products to Prevent Patient Harm” - March 2014 Human Factors and Ergonomics Symposium

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Education/Awareness across Multiple Domains of Interest

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• Risks Associated with the Design of Electronic Medical Records -Virginia Chapter of the American Society for Healthcare Risk Management – Spring Program May 2008

• Application of Human Factors Engineering Best Practices to the Redesign of a Laboratory Information Display – May 2011 National Patient Safety Foundation conference

• Risks to Patient Due to Incorrect Patient Record Selection – March 2013 Human Factors and Ergonomics Symposium

• Product Vendors requests for evaluation techniques – influence external partners.


Questions?

Contact Information:Jeanie Scott ([email protected])

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mailto:[email protected]

ECRI Institute

Ronni P. Solomon, J.D.Executive Vice President and General Counsel

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Documents

Safety Task Force June 13, 2014. Task Force Members NameOrganization Members David Bates, chair Brigham and Women’s Hospital & Partners Peggy BinzerAlliance