This talk addresses the impact of health IT systems on patient safety. In particular, how health IT systems intended to reduce medical error can introduce a new set of risks. Understanding why this is so is related to the need for better understanding of "human error", one that goes beyond simply blaming the users who are at the "sharp end" of the stick. In particular, health IT systems need to be good “team players”. One of the keys to making Health IT systems good team players is user-centered design (UCD). Another is ensuring that human factors are incorporated into safety risk management, as recommended by the FDA for medical devices.

1. Making Health IT a Team Player
Ken Wong, Ph.D., Senior Systems Analyst
McKesson Medical Imaging Group
VanQ, January 29, 2009

2. Dec 2008 – Health IT alert
Technology-related adverse events also happen
when health care providers and leaders do not
carefully consider the impact technology can
have on health care processes, workflow and
safety.
─ Sentinel Alert Event, Issue 42, December 11, 2008,
The Joint Commission
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3. Overview
Medical Error
Unintentional Consequences of IT
IT as a Team Player
Being User Centered
Conclusion
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4. Medical Error

5. To err is human
As many as 98,000* people die each year from
medical errors that occur in hospitals. That's
more than die from motor vehicle accidents,
breast cancer and AIDS—making medical errors
the fifth leading cause of death in this country.
─ To Err Is Human: Building a Safer Health System,
Institute of Medicine, 1999
* 195,000 according to HealthGrades 2004 report
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6. Human error … again?
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7. Homer effect
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8. But …
Who put Homer in charge?
How was Homer trained?
Why did the system get into this state?
What other safeguards are in place?
Etc.
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9. Approaches to human error2
Person approach System Approach
─ Aberrant mental processes ─ Humans are fallible
─ Human error as causes of ─ Human error as
accidents consequences
─ Focus on those at the ─ Focus on upstream
“sharp end” of the stick systemic factors
─ Goal: Reduce human ─ Goal: Build system
variability defences
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10. Swiss Cheese Model
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11. Unintended Consequences of IT

12. Can you read my mind?
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13. IT to the rescue
e.g., Computerized Physician Order Entry (CPOE)
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14. We all fall down
… we found that a leading CPOE system often
facilitated medication error risks, with many
reported to occur frequently.
─ Role of Computerized Physician Order Entry
Systems in Facilitating Medication Errors, Ross
Koppel, et al., JAMA, March 2005
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15. Human error .. yet again?
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16. Unintended consequences of IT
As a consequence, PCISs might not be as
successful in preventing errors as is generally
hoped. Worse still, PCISs could actually
generate new errors.
─ Some Unintended Consequences of Information
Technology in Health Care: The Nature of Patient
Care Information System-related Errors, Joan S.
Ash, et al., JAMIA, Mar/Apr 2004
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17. IT as a Team Player

18. User (and workflow) is king
E.g., FAA controller
requirements
─ Conservative
─ Safety-critical
Standard Terminal Automation
Replacement System (STARS)
From hf.tc.faa.gov
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19. Workflow interruptus
Health IT implicit assumptions4:
─ Workflow is continuous and uninterrupted
─ Complete and structured information entry/retrieval
─ Workflow is linear, clear and predictable
─ Making information available is sufficient notification
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20. IT – savior vs team player
IT as savior IT as team player
─ IT replaces fallible people ─ IT supports workflow
─ People adjust to IT ─ IT & people work together
─ Health IT “experiments”5 ─ User-Centered Design
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21. Being User Centered

22. Being User Centered (at MIG)
Understand users and their workflows
─ Personas
─ Use Cases
─ Usability Testing
Identify use-related hazards
─ Hazard Analysis
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23. E.g., Usability Testing and Safety
Run through anticipated tasks and scenarios:
─ Identify any usability problems
─ Collect quantitative performance data
─ Determine participants' satisfaction
Incorporating safety:
─ Validate likelihood of identified hazards
─ Identify new hazards
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24. Worlds collide
Business
Analysis
User
Software Healthcare Centered
Engineering
Design
Safety
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25. Conclusion

26. Jan 2009 – Health IT chasm
The nation faces a health care IT chasm that is
analogous to the quality chasm highlighted by
the IOM over the past decade.
─ Computational Technology for Effective Health
Care: Immediate Steps and Strategic Directions,
Institute of Medicine, 2009
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27. Human error … never again?
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28. Changing the world
We cannot change the human condition, but we
can change the conditions under which humans
work
─ Human error: models and management, James
Reason, BMJ, March 2000
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29. References
1. To Err Is Human: Building a Safer Health System, Institute of Medicine,
1999
2. Human error: models and management, James Reason, BMJ, March
2000
3. Role of Computerized Physician Order Entry Systems in Facilitating
Medication Errors, Ross Koppel, et al., JAMA, March 2005
4. Some Unintended Consequences of Information Technology in Health
Care: The Nature of Patient Care Information System-related Errors, Joan
S. Ash, et al., JAMIA, Mar/Apr 2004
5. Hiding in plain sight: What Koppel et al. tell us about healthcare IT,
Nemeth et al., JBI, June 2005
6. Computational Technology for Effective Health Care: Immediate Steps
and Strategic Directions, Institute of Medicine, 2009
7. Medical Device Use-Safety: Incorporating Human Factor Engineering into
Risk Management, FDA, July 2000
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