BETHESDA, MD – The Agency for Healthcare Research and Quality (AHRQ) is testing a tool among physicians to identify and report patient safety risks and near misses that may arise from the interaction of health IT with other systems or as a result of software design.
The health IT hazard manager will ultimately be scalable for use as a national clearinghouse of health IT-related risks, near misses and safety incidents so they can be compared and analyzed and systems corrected.
The hazard manager enables providers to classify and communicate the unintended consequences of establishing electronic health records (EHRs) and other health IT system so the problems can be fixed or controlled before they reach the patient, said Dr. James Walker, CIO of the Geisinger Health System, which is one of seven providers testing the usefulness and usability of the software. Four health IT vendors also participate in the pilot.
“Otherwise, the hazard remains in the system and is available to trip up a health IT user to make an EHR-prompted error,” such as a wrong value for a physiologic reading, he said at the Sept. 19 AHRQ annual conference.
Researcher Abt Associates Inc., which has developed the software for AHRQ, will analyze the results from the test sites in November. In December, the test providers, health IT vendors and AHRQ and other agencies, including the Food and Drug Administration, which has an adverse event reporting system, will meet to plan next steps, said Andrea Hassol, Abt project director for the hazard manager. The vendor will update the software by May 2012.
Each provider organization that contributes data to the health IT hazard clearinghouse will be able to see and manage its own list of hazards as well as see an aggregated list of hazards reported by other customers of its vendors, with the information de-identified to protect the anonymity of the providers, Hassol said. Providers will also be able to view a complete list of hazards reported in the database with the information about providers and vendors de-identified.
Similarly, each vendor will be able to see all the risks and near misses attributed to its products to be able to use this information for product improvement. Policymakers and researchers will see a de-identified list of all of the accumulated hazards in order to support efforts to reduce such risks in future generations of health IT, she said.
The tool is geared more to controlling a prospective or potential hazard and less on “blame the user,” which has been a common sentiment, Walker said. Geisinger is emphasizing the reward of providers reporting hazards, fixing or controlling them as more likely to earn the public’s confidence. Geisinger trains staff to use the hazard manager and to report any potential risk.
“Just the existence of the tool changes the way health IT teams think about hazards. Sometimes you see things you may not have noticed before,” he said.