Joint Commission Sentinel Events Alert On Healthcare IT
The
contentious issues on this website, about which I have been writing for a
decade, have finally been validated by an organization with significant
authority over hospitals. Hospital leadership
should take note.
The Joint Commission for
accreditation of healthcare organizations in the
The text of the Joint
Commission alert is located at this URL:
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm
It should be read in its
entirety. I will comment on some of its
strengths and weaknesses below.
Noteworthy is the fact
that Biomedical Informatics specialists and their research figure heavily in
the Alert’s references.
I can only wonder what
motivated the Joint Commission to issue such a potentially industry-adverse
advisory (adverse to common health IT industry practices, that is) at this
time. Perhaps as cases of HIT difficulty
and patient harm become more commonly known, the Commission does not wish to
appear to have been caught unaware as have other regulatory agencies in the
face of recent turmoil in the housing and financial sectors.
That said, what I and a
number of others have been writing about for the past decade - in a contretemps
to the prevailing attitude of "irrational exuberance"
about healthcare information technology (electronic medical records,
computerized physician order entry, clinical decision support etc.), especially
under traditional information systems leadership, as a silver bullet to cure
healthcare's ills - has finally appeared from an organization that might
actually be listened to.
Listened to, that is, over the uncritical and conflicted calls of the Big
Business Consortia, the Information Technology industry, hospital management
information systems departments, the former
CEO of Intel, Bill Gates, and others that ignore the downsides of
healthcare IT and make it seem an easy, sure-win endeavor that will
“revolutionize” medicine. (I, for one,
would welcome a cessation of claims that IT will "revolutionize" any
field that depends primarily on cognition, such as biomedicine, and a return to
more temperate attitudes instead of the almost bellicose grandiosity about HIT
we see today. That is to say, that HIT - with proper contributions from the
appropriate specialties proportional to their relevant expertise - will
facilitate better health care, not "revolutionize" it.)
I believe this Joint Commission alert supports my contention that clinical
IT and business IT are two different subspecialties of IT, requiring
different approaches to leadership, conception, design, implementation and
lifecycle. As I have written, in the
name of healthcare improvement we as a society are trying to build clinical tools for complex, often
unforgiving medical settings that happen to involve computers, not information systems that happen to
involve doctors. We should consider the
practical and operational implications of this reality.
I also believe this Joint
Commission alert supports the contention of a number of people in my field that
leadership by formally trained and experienced Biomedical
Informatics professionals should be, when possible and when available,
the "Sine qua non" of healthcare informatics initiatives. I also
include those without formal biomedical informatics training but with much
experience in the research and methods of the field, and a track
record of applied success.
Human computer interaction, unintended consequences of healthcare information
technology, and other sociotechnical matters are
areas we study professionally, combined with actual medical experience. These
are areas not best left to ad hoc or on-the-job training or to “amateurs” in
business IT or medicine (amateurs not in a pejorative sense, but in the sense
that I am a radio amateur or “ham” with formal licensure after governmental
examinations and significant technical and applied telecommunications
experience, but not a telecommunications professional who should be, say,
leading a critical telecommunications initiative for a hospital or large
business).
Several of my comments on
the Alert appear below in bracketed [red italic].
Emphases in boldface are mine:
From
the Joint Commission, a new Sentinel Events alert on HIT
Safely implementing health information and converging technologies (excerpts)
Dec. 11, 2008
As health information technology (HIT) and “converging technologies”—the
interrelationship between medical devices and HIT—are increasingly adopted by
health care organizations, users must be mindful of the safety risks and
preventable adverse events that these implementations can create or perpetuate.
Technology-related adverse events can be associated with all components of a
comprehensive technology system and may involve errors of either commission or
omission. These unintended adverse events typically stem from human-machine
interfaces or organization/system design [a.k.a.
the academic "soft stuff" that Management Information Systems
personnel often scoff at - ed.]
The overall safety and effectiveness of technology in health care ultimately
depend on its human users, ideally working in close concert with properly
designed and installed electronic systems. Any form of technology may
adversely affect the quality and safety of care if it is designed or
implemented improperly or is misinterpreted. Not only must the technology or
device be designed to be safe, it must also be operated safely within a safe
workflow process.
... There is a dearth of data on the incidence of adverse events directly
caused by HIT overall. [This has been a chronic
problem partly due to, I believe, corporate and marketing control of the HIT
narrative, and ‘political correctness’ of the healthcare and academic
communities, at patient expense - ed.]
The United States Pharmacopeia MEDMARX database includes 176,409 medication
error records for 2006, of which 1.25 percent resulted in harm. Of those
medication error records, 43,372, or approximately 25 percent, involved some
aspect of computer technology as at least one cause of the error. Most of the
harmful technology-related errors involved mislabeled barcodes on medications
(5 percent), information management systems (2 percent), and unclear or
confusing computer screen displays (1.5 percent). The remaining harmful errors
were related to dispensing devices, computer software, failure to scan
barcodes, computer entry (other than CPOE), CPOE, and overrides of barcode
warnings. (See the sidebar for a breakdown of these data.)
... Contributing factors
Inadequate technology planning [It would be
extremely helpful in the Joint Commission explored how that happens, exactly -
ed.] can result in poor product selection [not to mention vendor favoritism and CIO conflicts of
interest - ed.], a solution that does not adapt well to the
local clinical environment, or insufficient testing or training. Inadequacies
include failing to include front-line clinicians in the planning process [unbelievably, this is not uncommon. What manner of IT and
executive personnel can make such imprudent decisions, the Joint Commission
should ask - ed.], to consider best practices [it is indeed puzzling that including clinicians in HIT is
not a "best practice" obvious even to, say, our computer literate
children - ed.], to consider the costs and resources needed for
ongoing maintenance, or to consult product safety reviews or alerts or the
previous experience of others [and the previous
and current experience of Biomedical Informatics professionals, I might add -
ed.]
... An over-reliance on vendor advice [in direct
terms, and in words the Joint Commission will not use, such advice is likely
tainted by conflict of interest - ed.], without the oversight of
an objective third party (whether internal or external), also can lead to problems.
“There’s often an expectation that technology will reduce the need for
resources, but that’s not always true,” says Bona Benjamin, BS Pharm, director of Medication-Use Quality Improvement,
American Society of Health-System Pharmacists. Instead, technologies often
shift staffing allocations, so there is not typically a decrease in staff.
Technology-related adverse events also happen when health care providers and
leaders do not carefully consider the impact technology can have on care
processes, workflow and safety. “You have to understand what the worker
is going through [It is unclear to me why it is
assumed that non-biomedical IT personnel
can truly do that - ed.] – whether that worker is a nurse, a
doctor, a pharmacist or whoever is using the technology. The science of the interplay
between technology and humans or ‘human factors’ is important and often
gets short shrift,” says Ronald A. Paulus, M.D.,
chief technology and innovation officer, Geisinger
Health System.
If not carefully planned and integrated into workflow processes, new technology
systems can create new work, complicate workflow, or slow the speed at which
clinicians carry out clinical documentation and ordering processes. Learning to
use new technologies takes time and attention, sometimes placing strain on
demanding schedules. The resulting change to clinical practices and
workflows can trigger uncertainty, resentment or other emotions [and behaviors such as active and passive aggression - ed.]
that can affect the worker’s ability to carry out complex physical and
cognitive tasks.
For example, through the use of clinical, role-based authorizations, CPOE
systems also exert control over who may do what and when. While these
constraints may lead to much needed role standardizations that reduce
unnecessary clinical practice overlaps, they may also redistribute work in
unexpected ways, causing confusion or frustration. Physicians may resent
the need to enter orders into a computer. Nurses may insist that the physician
enter orders into the CPOE system before an order will be carried out, or
nurses may take over the task on behalf of the physician, increasing the
potential for communication-related errors.
Physicians have reported a sense of loss of professional autonomy when
CPOE systems prevent them from ordering the types of tests or medications they
prefer, or force them to comply with clinical guidelines they may not embrace,
or limit their narrative flexibility through structured rather than free-text
clinical documentation [and business IT and
technical personnel often with insufficient human-skills levels may be assigned
to "fix" the problems. Talk about being in over your head- ed.]
Furthermore, clinicians may suffer “alert fatigue” from poorly implemented CPOE
systems that generate excessive numbers of drug safety alerts. This may cause
clinicians to ignore even important alerts and to override them, potentially
impairing patient safety.
Read the whole thing.
Then compare the Dec. 2008 alert to what I've been writing at this website on
HIT difficulties, founded in 1998.
It's been a long time in coming,
indeed.
I can add that the most critical "best practice" for
healthcare organizations generally, and healthcare IS departments in particular
regarding HIT, is the practice of knowing what you do not know,
admitting you do not know it, finding out who does know, and then
utilizing those experts maximally.
Perhaps thanks to this Joint Commission Alert, we won't have to wait for
cybernetic version of a "Libby
Zion event", or for the following to occur until healthcare
organizations finally
realize the importance Biomedical Informatics and leadership of
healthcare IT, and start acting on the realization.
Addendum:
Some have labeled me a
"skeptic" of HIT. I'm not a skeptic at all. I've seen the technology
work, in various settings. I've made it work in various settings, some rather
unusual (e.g., in a Middle Eastern oil producing country where I once would not
have been allowed to travel at all, let alone work on HIT for improving care of
children).
I'm in fact a skeptic of the way health IT is currently pursued, especially its
leadership model and costs based on a management information systems paradigm
in design, implementation and lifecycle. HIT is not MIS, and pursuit of HIT as
if it is MIS will cause continued difficulties, increased expense, and impaired
diffusion.
I'm also a skeptic of the shroud of mystery and in fact a form of censorship
that goes on towards its failures, failures largely caused by a 'Bull in a
China Shop' approach to HIT. That approach is mediated by false assumptions and
underestimations of HIT sociotechnical issues by an
inappropriate leadership. That my academic website on HIT difficulties remains
nearly unique after ten years,and that there is so
little information on HIT difficulties on the web, is in many ways remarkable.
Done right, HIT can succeed. See for example the text "Medical Informatics
20/20" for "best practices" that mean something.
The Joint Commission report should, in fact, be unnecessary. Much of what it
states is obvious. That its findings need to be stated as an
"alert" at all is perhaps reflective of the above problems.
"Gadfly towards ill informed HIT leadership practices" might be a
more precise term to describe my work.