This year promises to be a busy one on the health IT front, with increasing developments in health information exchanges, the incorporation of meaningful use Stage 2 requirements and the general push toward greater transparency in many areas of health care delivery to boost interoperability.
iHealthBeat asked the following six health IT thought leaders to offer their views on the key health IT safety-improvement opportunities ahead and some of the persisting challenges:
- John Halamka, CIO of the Beth Israel Deaconess Medical Center and CIO and Dean for Technology at Harvard Medical School;
- Lawrence Hanrahan, principal at PricewaterhouseCoopers' Health Industries Practice;
- Devin Jopp, president and CEO of the Workgroup for Electronic Data Interchange;
- Blackford Middleton, chair of the American Medical Informatics Association and chief informatics officer for Vanderbilt University Health System;
- Jacob Reider, chief medical officer at the Office of the National Coordinator for Health IT; and
- Ferdinand Velasco, chief health information officer at Texas Health Resources and chair of the Healthcare Information and Management Systems Society's Quality, Cost and Safety Committee.
iHealthBeat: Where are the big opportunities this year in using or better equipping health IT to improve patient safety in care settings?
Halamka: Using health information exchanges' "pull" capabilities, as we're doing in Massachusetts, so that if a patient arrives in the emergency department with nothing more than his wallet, we can pull information from multiple [electronic health records]. Integrating the personal health record and engaging patients' families are also important because there's really no way that we can deliver safe, quality care unless we have ubiquity of information among providers and patients. The good news is that it's all really happening; 2014 will be a pivotal year for [health] IT adoption and implementation because we've got more plug & play capability than ever before.
Middleton: The health care system has made tremendous headway in [health] IT adoption. The key now is to ensure that we're driving the value of that investment -- that clinicians use the tools to deliver zero-defect care. That's the goal: Ensure we're doing everything we know how to do right; that the best evidence is applied to every decision; and that advanced care protocols are used effectively. That goes beyond meaningful use-kind of decision support to look at decision support over the lifetime of care.
On the positive side, we now have the first class of board-certified clinical informaticians. So finally, there is a professional cadre of folks who know how to translate knowledge into practice, which is what we need for the transformation of U.S. health care.
Reider: The big opportunities are in taking advantage of Stage 2 meaningful use and the 2014 certified EHR technology because these capabilities represent a significant improvement in several domains, including interoperability and usability. And patient safety [improvement] is a byproduct of that interoperability -- the sharing of patient information such as medication alerts or allergies between and across systems.
iHealthBeat: Where should chief technology officers, chief medical information officers and product vendors focus their safety improvement efforts this year?
Halamka: I would argue that [what's needed] is not so much a technology issue as it is an education and policy issue. For example, do doctors in health care systems actually understand all of the community-based electronic health resources available and do they understand the local HIE strategy and the plan for how meaningful use Stage 2 will be rolled out in their hospitals? So I think organizations should spend a lot of time on education and policy -- on ensuring clinicians are using the technology that's available.
Hanrahan: There should be a focus on continued implementation of bar-code medication administration at the bedside and all venues where medications are administered. Two other important areas are moving toward a fully reconciled medication history (including herbals and over-the-counter medications) through the continued expansion of health information exchanges.
Jopp: Patient identifiers continue to be a significant problem within the health care industry -- making sure that the patient we are treating is the "right" patient. In developing the 2013 WEDI Report, we encountered reports of institutions with patient-matching problems greater than 20%. WEDI believes that there needs to be a patient identifier, not just a patient-matching strategy.
Middleton: The focus areas for CMIOs and CTOs in smaller health systems would be improving clinical decision support, knowledge sharing and [health IT] usability/clinical documentation, and interoperability. That's a good list for this year.
Velasco: Usability is one. A lot of the focus on optimizing [health IT and EHR] usability has been aimed at improving clinician workflow efficiency. This has been critical to achieving adoption, but we need to be more intentional now in considering the safety implications of usability as well. Are we consciously looking for risks of errors when evaluating new or existing functionality? Are we systematically checking to see if clinicians are making mistakes when using the system, while providing training or point-of-care support?
iHealthBeat: Which health IT developments, even if nascent, show considerable promise for improving safety across the care continuum?
Halamka: I think the most promising area is Big Data, driven by the Affordable Care Act. In my health system, Beth Israel Deaconess and its affiliated five hospitals are aggregating and normalizing data from multiple clinical and financial data sources for the purpose of understanding quality and cost variations. I see a huge acceleration on the [business intelligence] analytics front, which will improve safety ultimately. We should also hope that the technology and more home-care devices like scales, blood-pressure cuffs and glucometers will start to get interfaced to the ecosystem. If we're interested in a health care system, not a sick-care system, that ability to reach into the home with telemetry and patient-generated data is pretty important.
Hanrahan: There is promise in increasing on-the-go connectivity using smartphones. Incorporating [patient] reminders, for example, and real-time biometrics tracking with integration to the [EHR] are technology areas that can improve safety.
Jopp: A promising area is the innovative encounter models -- e-visits, for example -- being developed. Clearly, the ability to see your doctor remotely offers significant opportunities in the ambulatory setting and assists in patient follow-up. Another emerging area is the ability for patients to be remotely monitored after [hospital] discharge using mobile devices, which provides a unique opportunity for lowering readmissions due to complications. Overall, we (WEDI) believe that using technologies to engage patients remotely has significant opportunities for improving safety and outcomes.
Middleton: Genomic-based decision support -- taking into account a patient's gene variance for genes that affect drug metabolism and [guiding] physicians on appropriate drug dosing based on that gene profile -- is a promising area for [delivering] safety benefits.
Reider: We (ONC) have been so impressed with the work that many care-delivery systems and states are doing to leverage [patients'] health information using [health] IT -- which clearly is improving safety. It's been a heavy lift, we recognize, and meaningful use Stage 2 will be a heavy lift, too, so it's important to celebrate the successes that organizations and states are seeing.
Velasco: An emerging technology that I think has a lot of promise is real-time location and sensing systems (RTLS). These systems can help care teams and operational leaders gain a better understanding of the location, status and movement of patients, clinical staff and equipment within the health care environment. Besides the more apparent benefits in terms of improving operational efficiency, these systems can be leveraged to gain insights for infection prevention.