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1
Introduction
“To Err Is Human”
“Crossing the Quality Chasm”
Together, the above phrases—titles of reports—catalyzed a revolution
in American health care to ensure patient safety and improve quality of
care. To Err Is Human estimated that 44,000-98,000 lives are lost in hospi-
tals every year due to medical errors and led to the widespread recognition
that health care is not as safe as it should be (IOM, 1999). With an em-
phasis on improving quality,1 better results were thought to be achievable
(IOM, 2001).
Subsequent research further documented the deficiencies in the quality
and safety of American health care. Early work found evidence-based
practice is only followed 55 percent of the time (McGlynn et al., 2003),
and ensuing studies have reconfirmed that medical errors continue to be
prevalent, as more than 1.5 million preventable adverse drug events occur
annually (IOM, 2006). Adverse events can result from almost any type of
interaction with the care system, at any point during care delivery, and in all
care settings. Events can be the result of human, technological, and systems
errors and can be classified as errors of commission (a direct consequence
of treatment) or errors of omission (failure to undertake an action that
should have been completed). Specific to safety, there has been a tendency
to assume that a focus on quality will of necessity result in improved safety.
1 The Institute of Medicine (IOM) identified six aims of quality improvement, stating that
health care should be safe, effective, patient-centered, timely, efficient, and equitable (2001).
15
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16 HEALTH IT AND PATIENT SAFETY
This assumption may have delayed awareness of the need for a robust
framework focused on safety alone.
Perhaps more important, these studies brought to light the critical
concept of systemness, which recognizes that health care is a collection of
disparate fragmented parts with many individual actors, each seeking to
do their best by the patient instead of health professionals within a com-
prehensive “system.” This lack of systems to improve coordination in part
fostered the promulgation of poor-quality, unsafe health care. Although the
attention to systems of care have increased greatly, many of the efforts in
the 10 years since To Err Is Human and Crossing the Quality Chasm have
focused on processes of care as a first step, with the end goal of creating a
comprehensive system of high-quality and safe care. These studies and those
in the next section focused on quality and safety in health care overall.
This background is needed to understand the context for discussing patient
safety related to health information technology (health IT).2
PATIENT SAFETY
More than 10 years since these landmark patient safety reports, there is
considerable controversy about how much improvement in safety has actu-
ally occurred. Clearly some progress has been made with respect to specific
processes, such as high rates of prescribing beta-blockers at discharge to
patients presenting with an acute myocardial infarction (Chassin et al.,
2010), and significantly reduced surgical mortality rates (Neily et al., 2010).
Nationwide efforts were undertaken to reduce the number of medical errors
in all care settings, and campaigns were developed to increase awareness,
reduce risk factors, and develop a framework for high-quality care.
Despite these efforts, quality improvement throughout much of the U.S.
health care system is still proceeding at a glacial pace. The National Health-
care Quality Report by the Agency for Healthcare Research and Quality
(AHRQ) revealed that while nearly two-thirds of 179 measures of health
care quality did show improvement, the median annual rate of change was
only 2.3 percent. Several quality measures relating to cancer screening and
diabetes management actually worsened during this time (AHRQ, 2010).
In terms of safety, several new studies have recently been published sug-
2 Health IT is a term that is used somewhat interchangeably with other terms such
as health information systems, health information and communications technology, and
informatics. The terms are not necessarily defined the same way; for example, informatics—
defined as a scientific field that draws upon the information sciences and related technology
to enhance the use of the knowledge base of the health sciences to improve the health of
individuals and populations through care, basic biomedical and clinical research, education,
management, and policy—is a broader field than health IT. This report employs the term
health IT but recognizes these other, broader terms are also used.
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17
INTRODUCTION
gesting that patients continued to experience high rates of safety problems
during hospital stays. Indeed, one study found adverse events continue to
occur in as many as one-third of hospital patients (Classen et al., 2011).
These adverse events occur in hospitalized patients even in regions where
there has been a heavy programmatic focus on improving patient safety in
hospitals (Landrigan et al., 2010). Safety problems also plague Medicare
beneficiaries—a study suggests that more than 27 percent of Medicare ben-
eficiaries will experience an adverse event during their hospitalizations, with
half of these patients suffering more severe adverse events (HHS, 2010a).
These patient safety problems are not just limited to inpatient care. To
Err Is Human recognized that more patients could be harmed by errors
in ambulatory settings because more medical care is delivered outside of
hospitals than inside. A recent review of malpractice claims concluded that
52 percent of all paid malpractice claims for all physician services involved
ambulatory services, and almost two-thirds of these claims involved a major
injury or death (Bishop et al., 2011).
Important differences exist between the inpatient and ambulatory set-
tings regarding patient safety, including the types of errors seen (IOM,
1999), the relative importance of patient responsibility for following
through on care decisions, and the different organizational and regula-
tory structures in place (Gandhi and Lee, 2010). As a result, it cannot be
assumed that interventions to improve hospital safety will be applicable
in the ambulatory setting, which deserves focused attention of its own. In
recognition of this, an expert consensus conference to establish an agenda
for research in ambulatory patient safety recognized that knowledge of
ambulatory patient safety was lacking (Hammons et al., 2001). A recent
10-year review of ambulatory patient safety literature concluded that some
progress has been made in understanding ambulatory safety, major gaps
remain, and virtually no experiments or demonstrations have been done
that show how to improve it (Lorincz et al., 2011).
This new refocus on patient safety as a specific system priority is best
exemplified by a new Department of Health and Human Services (HHS)
initiative with a sole focus on patient safety. Policy makers have recently
recognized the significant challenges in improving patient safety across the
continuum of care and the lack of progress over the past decade. HHS
recently announced a national initiative called the Partnership for Patients,
aimed at reducing preventable hospital-acquired conditions and complica-
tions, that would result in about 1.8 million fewer injuries to patients and
would save more than 60,000 lives over 3 years. The partnership also aims
to reduce preventable complications during care transitions, thereby cutting
hospital readmissions by 20 percent from 2010 levels (HHS, 2011). This
may herald a new national focus on patient safety over the next decade in
the United States.
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18 HEALTH IT AND PATIENT SAFETY
As these findings indicate, the opportunity to continue to improve is
great, with many tools yet to be developed and effectively implemented.
In virtually every report on patient safety summarized above, health IT
has been identified as a critical tool to both measure and improve patient
safety. Yet despite the possibility that health IT can enhance the safety and
effectiveness of care, the widespread adoption and safe use of health IT
products is still relatively immature. Technical and organizational limita-
tions exist that can make health IT difficult to use effectively to improve
the safety and quality of care.
HEALTH IT
For the purposes of this report, health IT includes a broad range of
products, including electronic health records (EHRs),3 patient engagement
tools (e.g., personal health records), and health information exchanges;
excluded is software for medical devices (e.g., software in an implantable
cardioverter-defibrillator). The use of data support systems in health set-
tings began as administrative tools to facilitate billing processes and other
related transactions. More recently, health IT has evolved to EHRs and
other forms of technology that engage not just in transactions and data
storage but also decision support and the capacity for clinicians and pa-
tients to see the patient’s clinical progress and data more easily. Clinicians
and health care systems can potentially benefit from studying populations
of similar patients, leading to learning health care systems. Clinicians expect
health IT to support delivery of high-quality care in several ways, includ-
ing storing comprehensive health data, providing clinical decision support,
facilitating communication, engaging patients, and reducing medical errors.
In the near future, it is likely that patients, particularly those with chronic
illnesses, will consistently use the Internet to track their own health through
personal health records and handheld device applications. Current health IT
products are still improving their capacity to increase communications and
reduce errors by making the right thing to do easier to do. It is important
that health IT maximize patient safety while minimizing harm.
Adoption of health IT has been slow and is not yet widespread in the
United States. Although adoption rates have increased significantly over the
past decade, only 50.7 percent of office-based physicians use any type of
EHR, with 10.1 percent reporting use of a fully functional record (Hsiao
et al., 2010) (see Figure 1-1).
3 In this report, electronic health record will be used as the desired term over electronic medi-
cal record because it is more inclusive of the way electronic records are being used currently.
EHRs include clinical decision support tools, computerized provider order entry systems, and
e-prescribing systems.
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19
INTRODUCTION
60
Any
50.7
48.3 EMR/EHR
50
system
42.0
Percent of Physicians
40
34.8
29.2
30
24.9
23.9 Basic
21.8
20.8 system
18.2 17.3 17.3
20 16.9
11.8 Fully
10.5 10.1
functional
10 6.9
system
4.5
3.8
3.1
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
FIGURE 1-1
Percentage of office-based physicians with electronic medical
records/electronic health records: United States, 2001–2009
and preliminary 2010.
NOTES: Any EMR/EHR is a medical or health record system that is either all
or partially electronic (excluding systems solely for billing). The 2010 data are
preliminary estimates (as show by dotted lines), based only on the mail survey.
Estimates through 2009 include additional physicians sampled from community
health centers; prior 2008 combined estimates were revised to include those
physicians (4). Estimates of basic and fully functional systems prior to 2006
could not be computed because some items were not collected in the survey.
Fully functional systems are a subset of basic systems. Some of the increase in
fully functional systems between 2009 and 2010 may be related to a change
in survey instruments and definitions of fully functional systems between 2009 and
2010. Includes nonfederal, office-based physicians. Excludes radiologists, anesthesi-
ologists, and pathologists.
SOURCE: Hsiao et al. (2010); CDC/NCHS, National Ambulatory Medical Care Survey.
With respect to hospitals, 11.9 percent of U.S. hospitals use compre-
hensive EHRs (Jha et al., 2010). Many barriers to adopting health IT exist,
including the complexity of training needed to integrate systems into new
patterns and clinical workflows, the cost of acquiring and maintaining
health IT, and the lack of resources to overcome barriers to implementa-
tion. As a result, the current culture of care delivery is often not ready for
widespread safer and more effective use of health IT.
In contrast to the United States, other countries have achieved much
higher adoption rates of EHRs. Denmark has had fully electronic patient
records for 10 years, and countries such as the Netherlands, Australia,
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20 HEALTH IT AND PATIENT SAFETY
Singapore, and Canada also are much further along than the United States
(see Chapter 2). These countries report both efficiencies in operation and
reductions in prescription error rates. Problems associated with health
IT reported overseas, most recently highlighted in the United Kingdom’s
decision to end its National Programme for IT after spending £6.4 of the
£11 billion allotted for the program, reflect complex issues of contracts,
product capabilities, and vendor performance, not necessarily patient safety
(Whalen, 2011).
A report by the President’s Council of Advisers on Science and Technol-
ogy concluded that the full potential of health IT to improve the quality and
cost of health care has not yet been realized. Many advances will be needed,
from lifting barriers (e.g., eliminating the proprietary nature of products
to promote interoperability, broadening the ways in which data are used,
ensuring privacy and security) to more innovative and competitive health
IT products (PCAST, 2010).
In an effort to improve health care, the U.S. government has invested
and will continue to invest billions of dollars toward the meaningful use of
effective health IT in the hopes of improving the quality of care, decreas-
ing the cost of care through improved efficiency, and guiding clinicians
to choose the most effective care interventions. In 2004, the Office of the
National Coordinator for Health Information Technology (ONC) was
established by executive order within the Office of the Secretary of HHS. It
was created in statute by the Health Information Technology for Economic
and Clinical Health (HITECH) Act, part of the American Recovery and
Reinvestment Act of 2009. Working toward the goal of bringing EHRs to
all Americans by 2014, the mission of the ONC is to both coordinate de-
velopment of a national health IT infrastructure and support and promote
meaningful use of EHRs. The ONC is supported directly and indirectly
by several federal advisory bodies (ONC, 2011). Those directly involved
include the following:
• The Health IT Policy Committee was provided for in the HITECH
Act to make recommendations to the National Coordinator for
Health IT toward development of a policy framework for a nation-
wide health information infrastructure.
• The Health IT Standards Committee was established at the same
time as the Policy Committee for the purpose of making recommen-
dations regarding standards and certification criteria for the elec-
tronic exchange and use of health IT to the National Coordinator.
• The National Committee on Vital and Health Statistics was estab-
lished in 1949 to advise the Secretary of HHS in issues related to
health data, statistics, and national information policy. Its National
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21
INTRODUCTION
Health Information Infrastructure report created the vision for the
emerging system (NCVHS, 2001).
Indirectly, the ONC receives helpful advice from a number of groups,
including the advisory groups for the National Library of Medicine, AHRQ,
multiple Boards of Scientific Counselors of the Centers for Disease Control
and Prevention, the Visiting Committee on Advanced Technology of the
National Institute for Standards and Technology, and the multiple advisory
committees of the Food and Drug Administration.
In collaboration with many private efforts and other public agencies,
these groups have been instrumental in advancing the development of an
initial framework for health IT. Although these efforts have been essential
to advancing the state of health IT, much more work is needed before all
Americans will have access to health IT–assisted care.
Development of health IT–assisted care is also being encouraged by the
broader health policy environment. Safe, interoperable health IT is a foun-
dational component of strategies such as accountable care organizations
and the patient-centered medical home. The promise of these movements
to reduce costs and improve patient outcomes assumes that high-quality
patient data can be shared reliably and effectively among providers. These
movements, among others, are likely to influence the speed of adoption
and broaden the functions of health IT considerably (NCVHS, 2001). In
contrast to these possible future uses, it is clear that current health IT imple-
mentations are often complex, cumbersome, and brittle in ways that may
also have negative effects on clinician performance (AHRQ, 2009; HIMSS,
2009; PCAST, 2010).
INTERSECTION OF PATIENT SAFETY AND HEALTH IT
Health IT is not one specific product that, once implemented, can
automatically result in highly safe and effective health care. It encompasses
a technical system of computers, software, and devices that operate in the
context of a larger sociotechnical system—a collection of hardware and
software working in concert within an organization that includes people,
processes, and workflow. It is widely believed that, when designed and used
appropriately, health IT can help create an ecosystem of safer care while
also producing a variety of benefits such as reductions in administrative
costs, improved clinical performance, and better communication between
patients and caregivers. In this view, it can be a positive, transformative
force for delivering health care. However, the assumption that the afore-
mentioned benefits are highly correlated with health IT has not been
adequately tested, and there are some indications that the features needed
to acquire one benefit may actually frustrate efforts to achieve another.
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22 HEALTH IT AND PATIENT SAFETY
In particular, there is a growing concern that health IT designs that maxi-
mize the potential for administrative and economic benefit may be creat-
ing new paths to failure. Reports of health IT becoming a distraction or
cause of miscommunication raise the possibility that health IT may cause
harm if it is poorly designed, implemented, or applied. Poorly designed,
implemented, or applied, health IT can create new hazards in the already
complex delivery of health care, requiring health care professionals to
work around brittle software, adding steps needed to accomplish tasks,
or presenting data in a nonintuitive format that can introduce risks that
may lead to harm. Risks to patient safety also arise as a result of great
heterogeneity in health IT products. As health IT products have become
more intimately involved in the delivery of care, the potential for health
IT–induced medical error, harm, or death has increased significantly.
Examples of health IT–induced harm that can result in serious injury
and death include dosing errors, failing to detect fatal illnesses, and
delaying treatment due to poor human–computer interactions or loss of
data (Aleccia, 2011; Associated Press, 2009; Graham and Dizikes, 2011;
Schulte and Schwartz, 2010; Silver and Hamill, 2011; U.S. News, 2011).
The portfolio of research on health IT has included little regarding
the general impact of health IT on safety of clinical care. The evidence in
the literature about the impact of health IT on patient safety is mixed but
shows that the challenges facing safer health care and safer use of health IT
involve the people and clinical implementation as much as the technology.
The literature does reflect improvements in some areas in well-established
health care institutions, notably medication administration through use
of computerized prescribing and bar-coding systems. But the evidence of
health IT’s impact on patient safety beyond medication safety and across
the health care system is lacking. Although evidence suggests improvements
in safety can be made, some studies have found health IT to have no effect
on patient safety, and case reports such as those cited above show that it
can also contribute to harm.
Advanced technology can create some new paths to failure at the same
time that it blocks others. These new forms of failure are often hard to
anticipate and may go unnoticed or be misidentified until the introduction
of the new technology is well advanced. The resulting shift in the locus of
failure can make the evaluation of the impact of technology on safety diffi-
cult, especially if the contribution of technology to the new forms of failure
is not appreciated (Woods et al., 2010). Given the large investments being
made in health IT, there is a great need to ensure that the new technology
is actually improving safety of care.
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23
INTRODUCTION
IOM COMMITTEE
The ONC’s Health IT Policy Committee held a hearing on patient
safety and health IT in February 2010 and recommended the ONC “com-
mission a formal study to thoroughly evaluate health IT patient safety
concerns, and to recommend additional actions and strategies to address
those concerns” (HHS, 2010b). In September 2010, the ONC asked the
Institute of Medicine (IOM) to make recommendations about how public
and private actors can maximize the safety of health IT–assisted care (see
Box 1-1). In response, the IOM established the Committee on Patient Safety
and Health Information Technology.
The committee’s report comes at a point in time characterized by a
number of rather dramatic changes relating to health care in addition to
major national health insurance and financial reforms. First, the HITECH
legislation provides substantial incentives to accelerate the adoption of EHR
systems. Second, there is an ongoing movement away from the historical
BOX 1-1
Statement of Task
An ad hoc committee will review the available evidence and the
experience from the field on how the use of health information technol-
ogy affects the safety of patient care and will make recommendations
concerning how public and private actors can maximize the safety of
health IT–assisted health care services. The committee will produce a
report that will be both comprehensive and specific in terms of recom-
mended options and opportunities for public and private interventions
that may improve the safety of care that incorporates the use of elec-
tronic health records (EHRs) and other forms of health IT.
“Health IT–assisted care” means health care and services that incorpo-
rate and take advantage of health information technologies and health
information exchange for the purpose of improving the processes and
outcomes of health care services. Health IT–assisted care includes care
supported by and involving EHRs, clinical decision support, computer-
ized provider order entry, health information exchange, patient engage-
ment technologies, and other health information technology used in
clinical care.
The committee will (1) summarize existing knowledge of the effects of
health IT on patient safety; (2) make recommendations to HHS regarding
specific actions that federal agencies should take to maximize the safety
of health IT–assisted care; and (3) make recommendations concerning
how private actors can promote the safety of health IT–assisted care, and
how the federal government can assist private actors in this regard.
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24 HEALTH IT AND PATIENT SAFETY
model of physician autonomy to one focused on adherence to evidence-based
guidelines and best practices that promote safe, high-quality care. Finally,
the practice of medicine is inexorably moving from being based primarily
upon knowledge of organs and organ systems to being based upon genomics
and proteomics, which has major implications for data management capa-
bilities. The aggregate impact of these tectonic shifts beneath health care and
its related technologies and treatments is one that requires development of
more complex yet reliable systems to assure high performance in the midst
of great baseline challenges to achieving excellent outcomes.
Scope
In his statement to the committee, David Blumenthal, the then–National
Coordinator, asked the committee to consider the full range of activities avail-
able in developing recommendations to assure the safety of health IT–assisted
care (Blumenthal, 2010). The statement of task defines health IT very broadly
and includes multiple types of technologies used in the delivery of health care
services. The committee considered all stakeholders as having important roles
in improving patient safety with respect to health IT. This includes patients
and their families, health professionals, health care delivery organizations
(ranging from small physician offices to large hospital systems), health IT
vendors, accrediting agencies, professional societies, insurance companies,
and the government.
Controversy exists regarding the impact of both the introduction of
health IT and the use of health IT on patient safety. Proponents argue that
published literature from trials generally support the claim that health IT
can reduce particular types of failure, improve quality and safety, and re-
duce costs. Critics point to reports of health IT failures. This report does
not attempt to resolve the controversy; instead it seeks to assess some of the
important issues surrounding health IT and its introduction and to indicate
the activities most likely to bring the potential value of health IT to the U.S.
health care system. Therefore, while the committee recognizes that both
risks and benefits are associated with health IT, it interpreted its charge as
making health IT–assisted care safer so that the nation is in a better position
to realize the potential benefits of health IT.
The committee did not examine a number of issues related to health
IT, including whether health IT should be implemented, access to health
IT products, medical liability, privacy, security, and standards. These are
critical for the ONC to address in order to achieve its mission of having
widespread use of EHRs by 2014. Similarly, the validity and use of infor-
mation from common Internet sites applied to specific patient situations
during delivery of care is also important in the changing health care delivery
environment but was not considered in the scope of this report. The com-
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25
INTRODUCTION
mittee also did not consider recommendations to address the broader issues
associated with health care safety. This report focuses on patient safety as it
relates to health IT and the delivery of care and will therefore concentrate
on the aspects of health IT directly pertaining to safety.
Methods
To address the statement of task, the committee conducted a wide-
ranging evaluation of the literature to gather evidence about patient safety
and health IT (see Appendix B) and received input in a variety of forums.
Over the course of this 12-month study, the committee met in person three
times. The committee also benefited by engaging with the public during
two workshops where it received statements from various stakeholder
organizations. Additionally, the committee solicited input from the public
and specifically the EHR vendor community.4 Public comments included
both statements about how a health IT product had improved the safety
of an organization as well as instances of harm. Vendors described various
processes adopted to both receive and handle customer-submitted reports
of patient safety issues, some appointing a formal team to guide follow-
on actions. However, when asked about the volume and types of adverse
events related to their EHR products, vendor responses ranged from 0 to 40
events per year, although none provided a full list of problematic events and
potential patient safety concerns (IOM, 2011). The committee considered
all these statements over the course of its deliberations and weighed them
against the literature and its expertise. Given the committee’s limited ability
to verify statements from the public and vendors, it did not systematically
weigh these statements.
RECOMMENDATIONS FROM PREVIOUS
IOM REPORTS REGARDING HEALTH IT
For more than two decades, the IOM and the National Academy of
Sciences have recognized health IT as a central component of a safe, high-
quality health care system. The first uses of computers for medical informa-
tion and records were primarily for reporting the results of laboratory tests
and for administrative purposes, particularly billing. It was only later that
they began to be used for a wider array of clinical uses, in particular as a
supplement to or replacement for paper for holding medical record data.
The growth of computing technology led the IOM to form a committee in
4 In this report, the term vendor is used to mean companies that design, make, and sell
health IT products. In many industries the terms developers and manufacturers are also used,
but in health IT, vendor is generally the preferred term.
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26 HEALTH IT AND PATIENT SAFETY
1989 to examine this development and make recommendations relating to
the future of computers in record keeping. The report of this committee
was entitled The Computer-Based Patient Record: An Essential Technology
for Health Care and it explained the contrast to the traditional paper-based
medical record. Lawrence Weed had described his problem-oriented medi-
cal record in 1969 and it was being developed in a computer-based format
in a system known as the problem-oriented medical information system
(PROMIS). The IOM report made a number of important conceptual
contributions well ahead of the maturation of the technology and its uses
in health care by focusing first on the patient, making it clear that patient-
centeredness was primary, and that the key was not who was entering the
information into the record. Clearly, it denoted that the record was based
upon a computer and not on paper. The subtitle focused upon health care,
not medical, nursing, public health, or any other subcategory relating to
health-related activities for which a record was kept. In that sense, it was
not envisioning an electronic medical record, but a record for medical care
as well as any care relating to health at that time.
Finally, The Computer-Based Patient Record identified a list of 12
functions that a record should properly serve. The committee’s vision was
very clear in the context of both its perspective and its functionalities. The
report was also limited in the sense that computer-based personal health
records and computer-based public health records have changed dramati-
cally since the time of its publication. The report reflected its time with a
focus upon the record as used in medical environments, but not solely for
medicine or medical care in the narrowest sense. It set a vision for nation-
wide computer-based patient records and called for electronic records to
be standard in care delivery and detailed primary and secondary uses of
electronic records (IOM, 1991). A later effort concluded that development
of robust data was critical to attaining this vision, requiring the creation
of data standards and collection of data for regional and national patient-
record efforts (IOM, 1994).
However, progress toward these goals was too slow (IOM, 2001), lead-
ing to the continued recognition that health IT is essential to reengineering
the health care system (IOM, 2001, 2003, 2004b; NAE and IOM, 2005).
Recommendations identified ways health IT could be advanced and in-
cluded the following:
• A renewed call for comprehensive national data standards to be
established and disseminated by the federal government for the
definition, collection, coding, and exchange of data (IOM, 2001,
2004b);
• A series of demonstration projects to develop a health IT
infrastructure—particularly in the areas of communication, access
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INTRODUCTION
to patient information, knowledge management, and decision
support—that would take place at the community, state, multistate,
and regional levels (IOM, 2003);
• Industry and government collaboration at a national level, for ex-
ample with the development of public–private partnerships (IOM,
2004a; NAE and IOM, 2005); and
• Large federal investments to support the development of a national
health information infrastructure to improve patient safety and
health care delivery (IOM, 2002, 2004b; NAE and IOM, 2005).
In 2003, the IOM reported that emerging competencies for the future
include knowledge, skills, and attitudes relating to (1) practice in teams,
(2) use of evidence-based knowledge, (3) continuously improving quality,
(4) patient-centered care, and (5) employing informatics. Education and
training must go beyond simply educating current clinicians on how to use
a specific EHR product. For safe delivery of health care in the future, health
professionals need to know how to work in complex systems. Understand-
ing health IT within the context of contemporary health reforms and chal-
lenges for improving safety and outcomes will be critical (IOM, 2004a).
Upon recognizing that many types of health IT exist to address many
different purposes, and can vary by setting of care, the IOM examined
specific components of health IT (IOM, 2004b). Particular emphasis was
placed on EHRs and reduction of medication errors. To help move the
field forward, the IOM described an EHR system as a system that “en-
compasses (1) longitudinal collection of electronic health information for
and about persons, (2) electronic access to person- and population-level
information by authorized users, (3) provision of knowledge and decision
support systems, and (4) support for efficient processes for health care
delivery” (IOM, 2004b). It identified eight key functionalities for EHR
systems: health information and data, results management, order entry
management, decision support, electronic communication and connectiv-
ity, patient support, administrative processes, and reporting and popula-
tion health management.
In an effort to emphasize the importance of preventing medication
errors, the effective use of technologies to reduce medication errors was the
focus of a different IOM committee. Agencies within HHS were identified
as actors to establish standards affecting drug-related health information
technologies, such as development of a common drug nomenclature to
be used in all clinical IT systems, specifications for alert mechanisms and
intelligent prompting, and optimum design of user interfaces for the clini-
cal environment. These recommendations were made to address patients’
unique characteristics and needs while also recognizing providers’ indi-
vidual prescribing, ordering, and error patterns (IOM, 2006).
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28 HEALTH IT AND PATIENT SAFETY
Despite the efforts made over the past few decades, a recent report by
the National Research Council (NRC, 2009) concluded that the current
investment in health IT is inadequate to fully realize the positive effects
IT can have to make health care more effective. If the promise of a high-
performing health care system is to be achieved, future efforts will need to
emphasize cognitive support for health care providers and patients, such
as enhanced decision making and problem solving, which will require an
interdisciplinary approach. In essence, the report sought to refocus atten-
tion to humans and away from technology as a simple solution.
REPORT STRUCTURE
This report consists of seven chapters, of which this introduction is the
first. The committee evaluates the current state of health IT in Chapter 2
and offers a systems approach for health IT safety in Chapter 3. Chapter 4
highlights opportunities to improve safety from the perspectives of both
manufacturers and users of health IT. The role of patients and their fami-
lies is explored in Chapter 5. The responsibilities of the private and public
sectors are explored in Chapter 6. Finally, the committee offers a future
research agenda for health IT safety in Chapter 7.
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