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HIE: 6 Opportunities for Increased Patient Safety

In my last blog post we explored the topic of shared decision making (SDM) and its impact on patient safety. This made me think of an experience we recently had with my dad. He had a stent placed about year and a half ago to open a blocked artery in his left anterior descending artery (LAD). Now I should tell you that the doctors, 3 to be exact, wanted to send him home because all of his tests came back negative, but the stubborn, yet lovable, man that my father is (I know, the apple doesn’t far fall!), found a cardiologist that was willing to listen to him and discuss his concerns and thoughts. He convinced this cardiologist to do an angiogram. They ended up finding, clear as day, a 90% blockage in the LAD and stented him right then and there, no questions asked. Needless to say he bypassed a major heart attack, (a.k.a. the Widowmaker) which could have very easily ended his life.

My brother and I both have clinical backgrounds, so it was a little unsettling how the events of the 48 hours with my dad transpired. We went from an emergency admission to nothing is wrong with him, he can go home, to he has a 90% blockage in his main artery that we need to stent right away. Talk about an emotional rollercoaster, but in the HIE benefitsend we were glad he was okay. However, at time of discharge, another shocking and disappointing incident occurred. The nurse was going over his discharge medication regime. As she was rattling off this medication list at a speed even a pharmacist couldn’t understand, she stated, “…and 10mg of Amaryl two times a day.” My dad, who has NEVER taken a pill in his life (we are Indian so turmeric is our answer to everything!) and was still a little out of it from the whole experience was unable to catch the error that just occurred. Luckily I was there to ask the nurse, “Are you sure it is 10mg and not 1mg of Amaryl?” Her response, “Yes that is what the order states.” Again, I challenged her, “Are you sure, because I thought the cardiologist told us after surgery it was 1mg of Amaryl.” She responded, “I can go check, but I am pretty sure this is correct”. I asked her to call the cardiologist and confirm as pretty sure was not good enough. Just as I suspected, it was an error in dosage. The order was for 1mg of Amaryl, twice a day, specific to before breakfast and dinner. At this point, given all that occurred, I began questioning everything she rattled off and requested (well, damn near demanded) that she go back and reconfirm the entire list. This was my dad, my best friend, I was not going to take any chances that his safety be compromised due to a medication error.

This is just one incident that thankfully didn’t end badly. However, every day patient safety is being compromised because information is not accurately or readily available. Up to 18% of the patient safety errors, generally, and as many as 70% of adverse drug events could be eliminated if the right information about the right patient is available at the right time. Health information exchange (HIE) makes this possible1.”

What is HIE?

HIE is the mobilization of healthcare information electronically across organizations within a region, community or hospital system2. “It provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer and more timely, efficient, effective, and equitable patient-centered care. HIE is also useful to public health authorities to assist in analyses of the health of the population2.”

Patient Safety Through HIE

David Kaelber and David Bates state, “Better patient safety through enhanced, technology enabled, HIE will directly improve patient safety because it will provide a more complete clinical picture of a patient1.” They have identified six patient safety opportunities through HIE1:

1. Medication Processing: Today, reducing medication errors and improving patient safety have become all too common of discussion topics. One study has estimated that over 100,000 deaths occur annually in the United States because of adverse drug events (ADEs), including both non-preventable and preventable ADEs1. Two of the most common medication errors are among those caused by drug-allergy and drug-dose information.

Drug Allergy: This involves checking drugs against known patient-specific drug allergies before the drugs are given to the patient1. As many as 18% of serious, preventable ADEs stem from practitioners having insufficient information about the patient before prescribing, dispensing, and administering medications3. Review of data from the Pennsylvania Patient Safety reporting System (PA-PSRS) reveals more than 3,800 reports of cases in which patients received medications to which they had documented allergies3. Another contributing factor is that it is typically the patient that is relied upon as the source of allergic reaction information and obtaining accurate information from patients can be difficult. Often times they forget or are not in a state in which they can communicate this information. A more robust HIE could greatly reduce the frequency of ADEs from known allergic reactions, by finding prior allergies that the patient may not have remembered, and by improving the accuracy of the allergy list prior to dispensing medication1. It is critical for healthcare practitioners to be able to find important information about a patient at the time of prescribing, dispensing, and administering medications3.

Drug-Dose: This involves being sure that the individual dose, dosing frequency, and total duration of medication fall within accepted general standards1. Dosing errors represent the most common type of medication error leading to preventable ADEs and account for up to 60% of prescribing errors1. HIE, through the introduction of technology such as computer-based physician order entry (CPOE) systems, can dramatically reduce the number of these errors by ensuring legibility and integrating decision support and safety-related functions4, as well as allowing the physician to have access to accurate patient information including patient demographic information such as age, medication history and medication allergies5. CPOE systems often check in real time for drug interactions, alert to known patient allergies, and calculate dose adjustments according to patient’s weight or renal function, decreasing significantly the likelihood of erroneous or unsafe doses4.

2. Laboratory Processing: Laboratory services have a great influence on clinical decision making as 60-70% of the most important decisions on admission, discharge, and medication are based on laboratory test results1. Patient safety can also be improved by enhanced laboratory information processing enabled by HIE. The two primary areas for this include (1) helping to ensure that indicated lab testing is ordered and (2) helping to guarantee that lab test results (especially abnormal results) are appropriately followed up on1. HIE is particularly critical in this process given our era of few in-office tests, many “send-out” tests, and numerous independent laboratories1. HIE will allow for more effective integration between automation and information management, which is crucial for assuring process control that allows labs to identify and improve on the critical steps in pre-, intra- and post-analytical phases6. Technological solutions, such as COPE, bar-coding identification of patient and related samples, and increased strategies for sharing information, such as HIE, have the potential to make laboratory services safe6.

3. Radiology Processing1:- Typically the provider ordering an imaging study is different from the provider interpreting the imaging study. Therefore, health information has to be exchanged between these two health professionals for the radiology study to be effectively ordered and interpreted. Patient safety can be enhanced in both of these areas of radiology information processing through improved HIE. For example, improved HIE could decrease adverse intravenous contrast reactions and decrease exposure to inappropriate radiology testing and unneeded radiation exposure. Probably more important for patient safety is improvement in HIE to ensure appropriate follow-up of abnormal radiology findings. For instance, up to 2% of abnormal mammograms were found to be lost to follow-up without enhanced information exchange.

4. Provider to Provider Communication1: Every year each patient has, on average, four outpatient visits with just over half of these visits being to primary care providers, approximately 40% to specialists, and approximately 10% to emergency departments. The result of these healthcare interactions is that many providers are involved with each patient every year and each of these encounters can provide valuable information for the patient’s future care. Throw in the fact that these different primary care providers and/or subspecialists are managing different medical issues, effective information sharing becomes critical, but does not always occur. In these types of scenarios, patient safety can be jeopardized due to the lack of HIE among these providers. Patients routinely present to emergency departments outside of their normal healthcare system, sometimes unable to communicate, where their providers may have little or no prior information about them. Providers who do not know the patient, either in an inpatient or outpatient setting, make safer decisions with improved HIE. Surgeries also present times when many significant decisions and changes in patient care occur, involving many providers, in a relatively short period and can result in significant erosion of patient safety if information is not readily available. Changes in location of care–for instance hospitals to home or nursing home settings–also present opportunities for HIE to improve patient safety. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in their medications across the continuum standard and others, have identified patient hand-offs as a key point of breakdown in patient safety.

5. Patient to Provider Communication1: No one should be more invested in their own healthcare safety then patients themselves. In our current healthcare paradigm, however, minimal HIE occurs with patients and healthcare organizations typically do not sufficiently recognize the key role that patients can play in ensuring their own healthcare safety. With the significant interest and impending growth of improved HIE with patients through personal health records (PHRs), many hope this paradigm will change. There are many ways in which HIE can improve patient safety through enhanced patient-provider communication. Examples include patients checking for errors in their medical history, adding additional valuable information into their medical records, following up on their own test results, reviewing medications and other healthcare instructions, and being able to communicate more quickly with healthcare providers when they think their safety may be at risk. PHRs may also allow providers to more quickly and more accurately provide information to their patients, which should improve patient safety.

6. Public Health Information Processing: A rapidly growing area of HIE is public health informatics1. Public health relies on data reported by health care partners, and information technology makes such reporting easier than ever7. The Department of Health is aware of a reportable disease or case requiring additional investigation and in possession of full patient identifiers8. Traditionally these additional investigations required multiple telephone calls, travel, and requests for paper records in order to conduct the investigation, but with the advent of HIE, the health department investigator simply becomes another user of the HIE system and queries the system for additional information on the patient in question, potentially decreasing the amount of time and effort necessary to complete the required investigation8. Patient safety could be greatly enhanced through this growth. Opportunities for improved patient safety in this area include post-marketing drug surveillance, infectious disease surveillance, biohazard surveillance, and environmental exposure surveillance1. For instance, in 2006 the Centers for Disease Control recommended expanding the age for childhood influenza vaccinations based on enhanced public health informatics HIE1.

The ability to exchange health information electronically is the foundation to improve health care quality and patient safety. Shapiro et al, states, “HIE aim’s to bring previously unavailable clinical data from patients’ disparate health records, which may be spread over multiple provider and payer networks, to the point of care where clinicians and their patients need it most.”7 Electronic HIE not only improves quality and safety through appropriate access, with speed and security to a patient’s vital medical information, but reduces costs and improves patient and provider satisfaction. HIE has the potential to drastically impact patient care and safety. The challenge, as David Kaelber and David Bates, acknowledge, will be “to develop healthcare systems capable of processing and utilizing the dramatic increase in information. Only then will the potential of improved patient safety through enhanced HIE be realized because we will have increased the percentage of time that the right information is presented to the right person at the right time so that the right healthcare decision can be made1.”

What do you think are some additional opportunities for patient safety through HIE?

Resources for this blog post:

  1. http://www.sciencedirect.com/science/article/pii/S1532046407000901
  2. http://en.wikipedia.org/wiki/Health_information_exchange
  3. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Sep5%283%29/Pages/75.aspx
  4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1174881/
  5. http://amcp.org/WorkArea/DownloadAsset.aspx?id=9300
  6. http://www.amesdata.com/upload/support_file_20130415881993.pdf
  7. http://www.ncbi.nlm.nih.gov/pubmed/21330598
  8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2137930/

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Priyal Patel

Priyal Patel is a healthcare industry expert, strategist and senior solutions architect for Perficient. With more than 10 years of healthcare industry experience, Priyal is a trusted advisor to C-level executives, senior managers and team members across clinical, business, and technology functions. Priyal has a proven track record of helping providers and health plans execute enterprise-level transformation to drive business, clinical, financial and operational efficiencies and outcomes.

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