2

Evaluating the Current State of Patient Safety and Health IT

Health IT creates new opportunities to improve patient safety that do not exist in paper-based systems. For example, paper-based systems cannot detect and alert clinicians of drug-drug interactions, whereas electronic clinical decision support systems can. As a result, the expectations for safer care may be higher in a health IT-enabled environment as compared to a paper-based environment. However, implementation of health IT products does not automatically improve patient safety. In fact, health IT can be a contributing factor to adverse events, such as the overdosing of patients because of poor user interface design, failing to detect life threatening illnesses because of unclear information displays, and delays in treatment because of the loss of data. Adverse events, such as these, have lead to serious injuries and death (Aleccia, 2011; Associated Press, 2009; Graham and Dizikes, 2011; Schulte and Schwartz, 2010; Silver and Hamill, 2011; U.S. News, 2011).

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 (see Box 2-1). The implementation of health IT, particularly complex health IT products, may result in less efficient systems and not give clinicians the flexibility they need to deliver the safest care possible (Greenhalgh et al., 2008). Currently, the relationship between these unintended consequences and the design, implementation, and use are not well understood.

This chapter uses the literature and experiences of health professionals to evaluate the impact of health IT on patient safety. The first several sections of this chapter discuss the challenges faced by health IT researchers by



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2 Evaluating the Current State of Patient Safety and Health IT Health IT creates new opportunities to improve patient safety that do not exist in paper-based systems. For example, paper-based systems cannot detect and alert clinicians of drug–drug interactions, whereas electronic clinical decision support systems can. As a result, the expectations for safer care may be higher in a health IT–enabled environment as compared to a paper-based environment. However, implementation of health IT prod- ucts does not automatically improve patient safety. In fact, health IT can be a contributing factor to adverse events, such as the overdosing of pa- tients because of poor user interface design, failing to detect life threatening illnesses because of unclear information displays, and delays in treatment because of the loss of data. Adverse events, such as these, have lead to serious injuries and death (Aleccia, 2011; Associated Press, 2009; Graham and Dizikes, 2011; Schulte and Schwartz, 2010; Silver and Hamill, 2011; U.S. News, 2011). 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 (see Box 2-1). The implementation of health IT, particularly complex health IT products, may result in less efficient systems and not give clinicians the flexibility they need to deliver the safest care possible (Greenhalgh et al., 2008). Currently, the relationship between these unintended consequences and the design, implementation, and use are not well understood. This chapter uses the literature and experiences of health professionals to evaluate the impact of health IT on patient safety. The first several sec- tions of this chapter discuss the challenges faced by health IT researchers by 31

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32 HEALTH IT AND PATIENT SAFETY BOX 2-1 Unintended Consequences of Health IT: A Look at Implementing CPOE Two pediatric intensive care units (ICUs) implemented the same elec- tronic health record (EHR) system with computerized provider order entry (CPOE) in Pittsburgh and Seattle. The Pittsburgh experience led to a significant increase in mortality, while the same system implemented in Seattle did not (Del Beccaro et al., 2006; Han et al., 2005). Later, several other children’s hospitals introduced the same CPOE system, leading to no change or even lower rates in mortality (Longhurst et al., 2010). The differing impact on mortality rates may be due to the hospitals’ differences in the implementation and use of the CPOE system. These differences, as illustrated by the Pittsburgh and Seattle pediatric ICUs, are highlighted below: Pittsburgh • pecific order sets designed for critical care were not created. S • hanges in workflow were not sufficiently predicted, resulting in a C breakdown of communication between nurses and physicians. • rders for patients arriving via critical care transportation could not O be written before the patients arrived at the hospital, delaying life- saving treatments. • hanges, unrelated to the CPOE system, were made in the administra- C tion and dispensing of medication that further frustrated the clinical staff, for example: o At the same time the CPOE system was installed, the satellite phar- macy serving the neonatal ICU was closed and medications had to be obtained from the central pharmacy, delaying treatment. o Emergency prescriptions were required to be preapproved, and all drugs were moved to the central pharmacy. Seattle • esearchers visited Pittsburgh to learn about problems associated R with their implementation of the CPOE system. • ntensive care staff was actively involved during the design, build, and I implementation stages. • pecific order sets were designed for ICU and pediatric ICU before S implementation. • ew order sets, based on the most frequently used orders, were cre- N ated to help reduce the time it takes a clinician to enter orders (Del Beccaro et al., 2006; Han et al., 2005).

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33 EVALUATING THE CURRENT STATE detailing the complexity of health IT and patient safety, the limitations in the literature to determine health IT’s impact on patient safety, and how the magnitude of harm is masked. The chapter then analyzes the literature to determine how individual components of health IT have impacted patient safety and how data from health IT can be leveraged to improve safety in different populations. Next, it describes how policy makers can learn from health IT experiences from abroad. COMPLEXITY OF HEALTH IT AND PATIENT SAFETY In general, health IT is not a specific product but is composed of components—such as computerized provider order entry (CPOE) systems and clinical decision support (CDS) systems—that are designed, imple- mented, and used differently by various vendors, health care settings, and users (Hayrinen et al., 2008). These differences can have dramatic effects on care processes including care design, workflow, and—ultimately—the quality and safety of the care delivered. When health IT is designed and implemented in a manner that complements how information is trans- ferred between health professionals and patients, the reliability of patient information—and therefore patient safety—can increase (Dorr et al., 2007; Niazkhani et al., 2009; Shah et al., 2006). However, when health IT un- expectedly alters workflow, it has the potential to hinder clinicians’ abili- ties to communicate patient information (Niazkhani et al., 2009), and it may result in increased cognitive workload, clinicians ignoring computer- generated information, continued reliance on various traditional modes of communication, creation of unsafe workarounds, and more time spent dealing with health IT than with patient care (Ash et al., 2009). Several important factors regarding how health IT products are designed and implemented can have meaningful effects on the collection, storage, and transfer of information, as well as the utility of the product. Slight varia- tions in these factors can have differing effects on how health IT impacts patient safety. Some of these factors include the following: • Decisions about implementation strategies (e.g., “big bang” versus incremental); • The degree to which users can configure their IT system and the approaches to such configurations; • Clinician training strategies; • Frontline use (e.g., the IT integration into and redesign of clinical workflow); and • Tools for analyzing and reporting results of care (e.g., quality improvement).

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34 HEALTH IT AND PATIENT SAFETY LIMITATIONS OF CURRENT LITERATURE TO DETERMINE HEALTH IT’S IMPACT ON PATIENT SAFETY Like all studies regarding patient safety, studies focusing on health IT and patient safety are complex and subject to a variety of methodological challenges. To provide generalizable knowledge about the impact of health IT on patient safety, the interaction of the factors listed in the previous sec- tion (e.g., frontline use) needs to be understood. However, very few studies to date have done so, resulting in major gaps in our knowledge regarding how health IT affects safety. While most of the literature examining the effects of health IT has focused on quality and processes of care, studies regarding the impact of health IT on patient safety have been narrowly focused on a few specific aspects of care. Given that adverse events (events resulting in unintended harm to a patient from a medical intervention [IOM, 2004]) are multifaceted and diverse, much of the literature that does center on how health IT affects patient safety has focused on prevention of medication errors, identification of patients at high risk for adverse events, and avoidance of documentation errors. Although much of this evidence suggests that IT can be helpful in improving patient safety, a number of studies have failed to find a benefit (Black et al., 2011; Culler et al., 2006; Garg et al., 2005; Reckmann et al., 2009). Many studies, including meta-analyses, offer strong evidence that com- puterization of prescribing can dramatically improve patient safety. These products were consistently correlated with lowering the frequency of medi- cation errors and may be able to reduce preventable adverse drug events significantly (Kaushal et al., 2003; Shamliyan et al., 2008; Wolfstadt et al., 2008). However, the degree to which health IT can lower medication errors varies widely among the different computerized prescribing systems used (Nanji et al., 2011). The evidence of similar impact outside of medication safety is much weaker (Bates and Gawande, 2003). Indeed, some systematic reviews con- clude that the current literature is insufficient to establish any beneficial impact of health IT on patient safety and health outcomes (Black et al., 2011; Garg et al., 2005; Reckmann et al., 2009). More recently, new data have emerged, suggesting that health IT can introduce new patient safety challenges into the health care system (Magrabi et al., 2010, 2011). These studies are unable to accurately quantify the number of people harmed by health IT. This inability of the committee to quantify the harm makes it difficult to understand the tradeoffs between the potential safety benefits and harms caused by health IT. The differing results found in the literature may be due to a variety of reasons. Among those reasons are the heterogeneous nature of health IT—including the differences in the products themselves, how they are

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35 EVALUATING THE CURRENT STATE implemented, and how they are used across care settings. Most studies focused on health IT and patient safety examined care at a single medical center, often with homegrown IT systems. Aggregating many single-center studies, such as those common throughout the literature, does not neces- sarily lead to the same outcomes as having a few studies that are conducted in a broader array of clinical settings. However, systematic reviews have attempted to aggregate these studies and have done so in inconsistent ways, often choosing to include low-quality studies while failing to include higher- quality ones. Therefore, the committee could not point to any systematic reviews or studies as representing the most definitive evidence of the impact of health IT on patient safety (see Table B-1). A major challenge in quantifying the harm that might result from health IT is the lack of data in this area. However, the absence of quantifiable evidence of health IT’s harm is not evidence that health IT does not create harm. It is clear that harm exists. The current literature does not sufficiently produce estimates on the harm that might result from health IT. For exam- ple, a recent study by Nanji et al. evaluated the frequency, types, and causes of errors associated with outpatient computer-generated prescriptions. The study evaluated 3,850 prescriptions and found 466 errors, involving almost 12 percent of the orders. Because the error rates varied widely between different computerized prescribing systems (from 5.1 to 37.5 percent), the authors strongly recommended that users evaluate the safety of each system (Nanji et al., 2011). However, the authors were not allowed to list which error rates and safety issues were associated with each particular system. Instead, the article prescribed a “vigorous vendor selection” process, which each potential user would have to go through in order to identify safety concerns of that system. Had the authors been allowed to identify specific systems with higher error rates, users could know which systems to avoid and could select systems with characteristics that would best fit their work- flow and safety needs. Studies with generic descriptions of health IT products and patient safety issues will be of little utility to users because health IT products— even those made by the same manufacturers—are heterogeneous, tailored to individual clinical settings, and have varying impacts on patient safety. Therefore, to assist users in selecting the safest health IT product for their unique clinical environment, studies need to be able to name specific health IT products, describe how those products have been implemented, and identify their impact on patient safety in different clinical environments. For example, as mentioned in Box 2-1, a Pittsburgh pediatric intensive care unit’s (ICU’s) implementation of a CPOE system resulted in higher mortality; however, several different hospitals were able to subsequently identify safety problems associated with Pittsburgh’s experience and imple- mented the same CPOE system with either no change or up to a 20 percent

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36 HEALTH IT AND PATIENT SAFETY decrease in hospital-wide patient mortality (Longhurst et al., 2010). In order to identify problems associated with the Pittsburgh implementation, a pediatric ICU in Seattle sent researchers to Pittsburgh’s facilities, met with their administrative and clinical leadership, and spoke with clinical staff. After months of correspondence, the Seattle pediatric ICU was able to determine why Pittsburgh’s implementation resulted in a higher mortality rate and was able to avoid such problems (Del Beccaro et al., 2006; Han et al., 2005). When selecting health IT products, many potential users do not have the time or the resources to spend months corresponding, visiting, and observing other hospitals. Users and researchers need to be encouraged to provide specific descriptions of safety problems associated with particular health IT products in order to provide potential users with credible data regarding which IT products are safer than others. BARRIERS TO KNOWING THE MAGNITUDE OF THE HARM When researchers, consumer groups, and users attempt to identify and share information on health IT features related to adverse events and patient safety risks, they can be faced with barriers created by market inefficiencies within health IT, such as lack of information available to consumers and the inability of users to freely move between health IT products. For example, because the impact of health IT in each clini- cal environment is extremely diverse and highly dependent on the user’s specific clinical environment, it is difficult for clinicians to know how the myriad of different health IT products will affect patient safety. Ad- ditionally, because of the substantial costs and effort used in tailoring and integrating health IT products, users may not be able to readily switch products after discovering patient safety problems. Many health IT prod- ucts can only be maintained by the manufacturer of that product, causing users to maintain service contracts with that manufacturer, regardless of whether that manufacturer addresses patient safety issues associated with its product. Even if users are willing to switch health IT products, there is no guarantee another product will achieve greater levels of patient safety, once integrated. These inefficiencies result in an inadequate understanding of how health IT impacts patient safety and leads users to select and make a long-term commitment to products that may not adequately complement their clinical environment. To increase understanding of how health IT affects patient safety and allows users to make informed decisions, it is important that the health IT community share details, such as screenshots of risk-enhancing inter- faces, descriptions of potentially unsafe processes, and other components of health IT products associated with adverse events. Some vendors allow users to share information through industry conferences, sponsored user

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37 EVALUATING THE CURRENT STATE group meetings, blogs, and consultants that provide conduits for informa- tion about vendor experiences. However, the ability of users and researchers to share such information outside industry-controlled venues can be limited by nondisclosure clauses. Nondisclosure clauses—commonly found in many types of commercial contracts and almost always included in software license agreements—are intended to protect licensors’ intellectual property interests, competitive edge, and liability from consumer misuse of their products1 (Koppel and Kreda, 2009). The fear of violating nondisclosure clauses and intellec- tual property interests may discourage users from sharing health IT– related patient safety risks. Additionally, if users believe that hold-harmless clauses, which are placed in many vendor contracts, can shift the liability of unsafe health IT features solely to the user, they may fear that disclosing unsafe features may unfairly increase their risk of liability. To adequately understand how health IT impacts patient safety, users and researchers need to be able to share information that may normally be protected by intellectual property rights or may expose users to un- fair liability. Some vendors have expended considerable effort to ensure patient safety, but allowing the disclosure of patient safety issues may cause vendors to lose their competitive advantage. Thus, some vendors may impose or enforce such restrictions in ways that may conceal patient safety issues2 (Koppel and Kreda, 2009). As long as vendors may restrict the release of information about safety issues through confidentiality clauses, intellectual property protections, and hold-harmless clauses, the health care community will be limited in its understanding of how health IT affects patient safety. Because the nature of these legal issues limits publicly available infor- mation, very little evidence establishes their frequency of use or impact on users (Koppel and Kreda, 2009). However, the committee believes that these types of contractual restrictions limit transparency, which significantly contributes to the gaps in knowledge of health IT–related patient safety risks. Regardless of whether these barriers have actually been used to prevent reporting, the fear of legal action itself may prevent health profes- sionals from sharing crucial health IT–related information with researchers, consumer groups, other users, and the government. As stated by the Ameri- can Medical Informatics Association, such clauses should be considered unethical (Goodman et al., 2011). 1 Personal communication, B. Leshine, LeClairRyan, April 20, 2011; personal communica- tion, H. Levine, Blaszak, Block & Boothby, LLP, June 10, 2011. 2 Personal communication, B. Leshine, LeClairRyan, April 20, 2011; personal communica- tion, H. Levine, Blaszak, Block & Boothby, LLP, June 10, 2011.

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38 HEALTH IT AND PATIENT SAFETY IMPACT OF HEALTH IT COMPONENTS ON PATIENT SAFETY The following sections examine how individual components of health IT affect patient safety. However, most health IT products are not a single component, but a complex system of health IT components, sometimes collectively referred to as electronic health records (EHRs). Although the definition of EHRs can vary substantially, there are generally four core components of an EHR: electronic clinical documentation (usually physi- cian, nurse, and other clinician documentation), electronic prescribing (e.g., computerized provider order entry), results reporting and management (e.g., clinical data repository), and clinical decision support (DesRoches et al., 2008; Jha et al., 2006, 2009a, 2009b). Many EHRs also include bar- coding systems and patient engagement tools. The Office of the National Coordinator for Health Information Technology (ONC) defines an EHR as “a real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decision-making. The EHR can automate and streamline a clinician’s workflow, ensuring that all clinical information is communicated. It can also prevent delays in response that result in gaps in care. The EHR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and reporting” (HHS, 2004; ONC, 2009). Although EHR and health IT are terms that are still evolving and are often interpreted differently, much of the evidence regarding the impact of EHRs on patient safety has focused on individual components of EHRs. The following sections explore the evidence for individual components and then discuss the evidence from studies that use the “EHR” as a general term.3 Because almost every component uses documentation and results review and management throughout their tasks (bar-coding, CPOE, and CDS systems all use documentation and results reporting and management in prescribing and delivering medication), this chapter will not address documentation results reporting and management individually. The section then looks at how current EHR systems can be leveraged to further improve patient safety. Table 2-1 summarizes the benefits and safety concerns com- monly found in the literature. 3 Although there are many other components of health IT, the bulk of the literature has focused on the following components: EHR, CPOE systems, CDS systems, patient engage- ment tools, and bar-coding systems. Some other components not listed in this chapter include medication reconciliation systems and smartpumps; see Appendix B.

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39 EVALUATING THE CURRENT STATE TABLE 2-1 Potential Benefits and Safety Concerns of Health IT Components Computerized Provider Order Entry (CPOE) An electronic system that allows providers to record, store, retrieve, and modify orders (e.g., prescriptions, diagnostic testing, treatment, and/or radiology/imaging orders). Potential Benefits Safety Concerns – Large increases in legible orders – Increases relative risk of medication errors – Shorter order turnaround times – Increased ordering time – Lower relative risk of medication errors – New opportunities for errors, such as: – Higher percentage of patients who at- • fragmented displays preventing tain their treatment goals a coherent view of patients’ medications • inflexible ordering formats generating wrong orders • separations in functions that facilitate double dosing • incompatible orders – Disruptions in workflow Clinical Decision Support (CDS) Monitors and alerts clinicians of patient conditions, prescriptions, and treatment to provide evidence-based clinical suggestions to health professionals at the point of care. Potential Benefits Safety Concerns – Reductions in: – Rate of detecting drug–drug • relative risk of medication errors interactions varies widely among • risk of toxic drug levels different vendors • time to therapeutic stabilization – Increases in mortality rate • management errors of resuscitating – High override rate of computer patients in adult trauma centers generated alerts (alert fatigue) • prescriptions of nonpreferred medications – Can effectively monitor and alert clinicians of adverse conditions – Improve long-term treatment and increase the likelihood of achieving treatment goals continued

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40 HEALTH IT AND PATIENT SAFETY TABLE 2-1 Continued Bar-coding Bar-coding can be used to track medications, orders, and other health care products. It can also be used to verify patient identification and dosage. Potential Benefits Safety Concerns – Significant reductions in relative risk – Introduction of workarounds; for of medication errors associated with: example, clinicians can: • transcription • scan medications and patient • dispensing identification without visually • administration errors checking to see if the medication, dosing, and patient identification are correct • attach patient identification bar-codes to another object instead of the patient • scan orders and medications of multiple patients at once instead of doing it each time the medica- tion is dispensed Patient Engagement Tools Tools such as patient portals, smartphone applications, email, and interactive kiosks, which enable patients to participate in their health care treatment. Potential Benefits Safety Concerns – Reduction in hospitalization rates – Reliability of data entered by: in children • patients, • families, – Increases in patients’ knowledge • friends, or of treatment and illnesses • unauthorized users NOTE: Table 2-1 is not intended to be an exhaustive list of all potential benefits and safety concerns associated with health IT. It represents the most common potential benefits and safety concerns. Computerized Provider Order Entry CPOE is an electronic system that allows providers to record, store, re- trieve, and modify orders (e.g., prescriptions, diagnostic testing, treatment, and radiology/imaging orders). The use of CPOE has varying degrees of impact on patient safety, depending on how well the CPOE system comple- ments or improves provider workflow. The successful impact of a CPOE system on patient safety may also depend heavily on the change manage- ment approach employed by organizational leadership to prepare clinicians and recipients of the new workflow, as well as the decision support tools associated with it. Short-term benefits of CPOE systems commonly found

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41 EVALUATING THE CURRENT STATE in studies include large increases in legible orders, shorter order turnaround times, lower relative risk of medication errors, and a higher percentage of patients who attain their treatment goals (Devine et al., 2010; Nam et al., 2007; Niazkhani et al., 2009). In the inpatient setting, a series of literature reviews and meta-analyses found that medication error rates fell (Kaushal et al., 2003; Shamliyan et al., 2008; Wolfstadt et al., 2008) due to the intro- duction of a CPOE system and most, though not all, studies suggest that the preventable adverse drug events (ADEs) rate decreases as well. Studies suggest that CPOE systems have a greater impact when designed for the specific needs of the hospital environment, workflow, and providers (Callen et al., 2010). For example, CPOE systems with order sets specifically de- signed for ICUs can increase efficiency and workflow (Ali et al., 2005). Although the potential benefits of CPOE systems are well established, the harms that have been well articulated on a case-by-case basis have rela- tively little empirical basis behind them (Aleccia, 2011; Associated Press, 2009; Graham and Dizikes, 2011; Schulte and Schwartz, 2010; Silver and Hamill, 2011; U.S. News, 2011). The lack of data on harm is driven in large part, as described earlier, by practices that limit disclosure of health IT–related adverse drug events. Based on the existing information, it seems likely that, if these systems are either designed poorly or interface with cli- nicians in an ineffective manner, they can cause harm. Several experts have suggested that CPOE systems can have a number of potential adverse con- sequences, including increased ordering time, disruptions in workflow, new opportunities for errors (e.g., fragmented displays preventing a coherent view of patients’ medications, inflexible ordering formats generating wrong orders, separations of functions that facilitate double dosing, and incompat- ible orders), and increased relative risk of medication errors (Koppel et al., 2005; Niazkhani et al., 2009; Santell et al., 2009; Singh et al., 2009; Walsh et al., 2006; Weant et al., 2007). Some of the variability in the impact of CPOE systems is likely due to differences in decision support systems that can detect potential errors and/ or generate care suggestions. For example, a CPOE system was introduced to a pediatric ICU without a CDS and resulted in no significant change in the rate of potential adverse drug events. However, a significant reduction in potential adverse drug events was found after a CDS system was imple- mented (Kadmon et al., 2009). Further discussion regarding the impact of CDS on patient safety is examined in the next section. Clinical Decision Support CDS systems are also an important component of an EHR. They can monitor patient conditions, prescriptions, and treatment to provide evidence-based clinical suggestions to health professionals at the point of

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48 HEALTH IT AND PATIENT SAFETY which health IT has played a key role. For example, the World Health Organization’s (WHO’s) patient safety program has 13 specific patient safety action areas that focus on patient safety as a global health care issue. These action areas are aimed to “coordinate, disseminate, and accelerate improvements in patient safety worldwide” (WHO, 2011a). Although it focuses on a broad range of safety issues, “Action Area 8: Technology and Patient Safety,” most specifically, targets systemic and technical aspects to improve patient safety around the world by promoting personal health records (PHRs), automated prescribing systems, simulation training, and failsafe mechanisms in diagnostic tools, such as computerized radiographs (WHO, 2008, 2011a, 2011b). On a similarly large scale, the European Union (EU) has funded specific eHealth initiatives (EU, 2010a) and the use of technology to improve the quality and safety of care delivered during disaster response efforts (EU, 2007). These programs focus on PHRs, patient guidance services, virtual physiological humans, and computer simulations. The EU is supporting sev- eral efforts using information and communication technologies to improve patient safety, focusing on the “development of advanced applications to improve risk assessment and patient safety” (EU, 2010b). In 2009 alone, the EU invested €28 million (EU, 2010b), including programs such as Patient Safety through Intelligent Procedures in Medication (PSIP), whose main aim is to develop computer applications and to educate providers and patients on how to prevent medication errors (PSIP, 2011). Additionally, the Safety for Robotic Surgery (SAFROS) project seeks to develop technologies for patient safety in robotic surgery (SAFROS, 2009). Broad country comparison studies have been conducted on the use of health IT and its potential to improve patient safety. For example, an international cross-sectional study examined health IT’s functional capacity and quality of care delivered in Australia, Canada, Denmark, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. The study found that, when controlling for within country differences of specific health IT methods adopted and primary care physician (PCP) prac- tice sizes, significant disparities exist in the quality of care delivered among practices with low IT capacity compared to those with high IT capacity. IT functional capacity was measured through a count of 14 different items (such as whether the clinician used an EHR, prescribed medicine elec- tronically, and had a computerized system for patient reminders, prompts for potential drug interaction, and test results). Practices were deemed “low” if they had 2 or fewer of the 14 items and “high” if they had between 7 and 14 items (Davis et al., 2009). Although the study focused on several outcomes, the specific safety outcome measured was whether a physician practice had a specific, docu-

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49 EVALUATING THE CURRENT STATE mented process for patient follow-up and analysis of adverse events. Thirty- eight percent of physicians had a documented process for all adverse events (ranging from 27 percent of physicians in low-capacity countries to 43 percent in high-capacity countries), while 17 percent of physicians had a process for adverse drug reactions online (ranging from 22 percent in low- capacity countries to 15 percent in high-capacity countries) (Davis et al., 2009). Approximately 50 percent of practices with low IT capacity reported no processes for following up on adverse events compared to 41 percent of practices with higher IT functionality. Researchers suggested that countries that support a stronger IT infrastructure are better suited to address coor- dination of care and safety issues, as well as to maintain satisfaction among the PCP community (Davis et al., 2009). Other country-specific studies have been conducted, including a series of papers comparing the adoption of health IT among PCP offices in New Zealand and Denmark, two countries leading the way in the adoption of health IT over the past two decades (Protti et al., 2008a, 2008b, 2008c, 2008d, 2009). These studies suggest that it has been possible for many nations to adopt and use health IT in PCP practices without measurable, deleterious consequences on patient safety. Although the United States has made significant strides in health IT over the past 20 years, it is clear that many other high-income nations are much further ahead in IT adoption, at least in the ambulatory setting. De- spite the fact that these other nations have had a much greater experience with health IT, there is very little direct information on the impact of their investments on patient safety. The primary lesson for the United States is that it is possible to have widespread adoption of health IT without harm- ing safety. What the optimal strategies are for doing so cannot be so easily gleaned by looking at these other nations. CONCLUSION Health IT has already been shown to improve medication safety. Al- though the evidence is mixed for areas outside of medication safety, both within the United States and abroad, the fact that several studies have im- proved patient safety with implementation of health IT leads the committee to believe that health IT has at least the potential to drastically improve patient safety in other areas of care. As with any new technology, health IT carries benefits and risks of new and greater harms. To fully capitalize on the potential that health IT may have on patient safety, a more comprehen- sive understanding of how health IT impacts potential harms, workflow, and safety is needed.

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