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An Analysis of Patient Safety Incident Reports Associated with EHR Interoperability
Tuesday, December 12, 2017

An Analysis of Patient Safety Incident Reports Associated with EHR Interoperability

With the widespread use of electronic health records (EHRs) for many clinical tasks, interoperability with other health information technology (health IT) is critical for the effective delivery of care.1 Providers can reduce patient safety events by improving connections among their electronic health records (EHRs) and their other health information technology (IT) systems. From a database of 1.735 million patient safety event (PSE) reports spanning multiple provider organizations, this AHRQ-funded study found 2625 reports, between 2009 and 2016, that were identified as being health IT EHR interoperability related. Rigorous review further identified 209 EHR interoperability related events.2 The most common events were associated with pharmacy, laboratory, and radiology, and involved poor receiving of EHR information from other IT systems.3 More than 50 percent of events reached the patient, but only 2 percent resulted in patient harm.4 The report conclusion supports the idea that providers should strive to improve EHR interfaces with other health IT systems.

1,2,3,4Adams, K.T.; Howe, J.L.; Fong, A.; Puthumana, J.S.; Kellogg, K.M.; Gaunt, M.; Ratwani, R.M. Applied Clinical Informatics. 8(2):593-602, June 2017.


Time to Adopt BIA in Radiology
Wednesday, December 7, 2011

Time to Adopt BIA in Radiology

Radiologists and other professionals in medicine should adopt business intelligence and analytics (BIA) according to Paul Chang, MD, at this year’s 2011 RSMA meeting. As part of Dr. Chang’s video clip shown on radRounds1, he says “you cannot improve a process until you can measure a process”. Metrics provides a means to measure process performance. Dr. Chang believes all of medicine lags in adopting metrics such as dash boards (systems that use triggers to let you know when you are exceeding specific criteria), balance score cards, and key performance indicators. The use of metrics helps us assess if a product we deliver to a patient is truly adding value and increasing quality while showing improvement and boosting efficiency. Other industries embrace IT tools that use BIA. However, medicine is just in the infancy of adopting BIA.2

Dr. Chang believes current information systems such as PACS and RIS used in radiology are not very good at measuring how well we do our work in a particular area. Today’s market is driving significant restraints where the goal is to add more value while using less resources and time. Better efficiency and higher quality must be a priority to compete in medicine. Using analytics can measure if one is doing a better or worse job in meeting their goal. BIA helps in operations, and addresses a key global and strategic question “am I adding value to my hospital, patient, and referring physician.”3

BIA uses business process modeling as a method for defining process flow. Once the process flow is determined, then key performance indicators can be defined, measured, and extracted. Quality data can then be compared to a goal. How well you perform in meeting the goal can be evaluated. If the quality data you measure falls outside a benchmark of acceptability, then an action plan such as education can be applied to help reach your goal.4


1,2,3,4radRounds Radiology Network (2011, December 7), Paul Chang MD Discusses Radiology Informatics at RSNA 2011. December 2011.

Call for EHR National Safety Oversight Board
Wednesday, November 23, 2011

Call for EHR National Safety Oversight Board

The Journal of Patient Safety1 recently published a report that calls for creation of a board that oversees the safety of electronic health record (EHR) systems. Complementing similar policy recommendations made by the Institute of Medicine (IOM), the report recommends the board review all reported errors classified as near misses and adverse events. The errors would be submitted to a national database for investigation, evaluation, and distribution of recommendations to minimize safety issues for other EHRs. Self-audits of EHRs would be promoted in collaboration with on-site audits by the board. The board would work with EHR certifying organizations to help improve the EHR system.2

1,2Singh, Hardeep; Classen, David C.; Sittig, Dean F. Journal of Patient Safety. 7(4):169-174, December 2011


IOM: Health IT and Patient Safety
Monday, November 21, 2011

IOM: Health IT and Patient Safety

A recent U.S. Institute of Medicine (IOM) report addresses recommendations regarding oversight of information technology in patient safety. The report recommends the U.S. Department of Health and Human Services (HHS) fund an IT safety council. The HHS should publish a plan within 12 months to help reduce risk associated with patient safety in health IT. The report also recommends the Office of the National Coordinator for Health Information Technology work with private sector to evaluate patient safety and sharing of information in health IT. Depending on the timely success of the plan to improve patient safety, the report recommends the U.S. Food and Drug Administration (FDA) be in a position, if required, to promulgate requirements for regulation of health IT.1

The report states HHS should create a process for both IT vendors and medical users to report deaths, injuries, or unsafe conditions associated with health IT. Vendors would be required to report such events. Medical users could report these events on a voluntary basis where confidentiality is maintained and no punitive action taken.2

The report stresses that health IT products should be designed utilizing principles of quality and risk management.3

1,2,3Institute of Medicine of the National Academies (2011, November 8), Committee on Patient Safety and Health Information Technology. To Improve Patient Safety, Health Information Technology Needs Better Oversight, Accountability; November 2011.


Algorithm-Based Treatment Decision Support
Thursday, November 10, 2011

Algorithm-Based Treatment Decision Support

The U.S. Department of Health & Human Services - Agency for Healthcare Research and Quality (AHRQ): Health Care Innovations Exchange was created to speed the implementation of new and better ways of delivering health care. The Health Care Innovations Exchange (Exchange) provides a process for health professionals and researchers to "share, learn about, and ultimately adopt evidence-based innovations and tools suitable for a range of health care settings and populations." The Exchange issues a periodic newsletter that describes various health care innovations. In their November 10, 2011 newsletter (issue #328), a recently submitted innovation described a hospital that uses a simple algorithm and related tools to guide physician ordering of diagnostic imaging studies. This process lead to reducing unnecessary radiation exposure for patients. The newsletter also describes QualityTools that utilize several other algorithms that support decision-making in the "prevention, treatment, and evaluation of various health conditions and diseases." A number of other innovations and tools related to the use of algorithms in patient care are available on AHRQ’s Health Care Innovations Exchange website.

The Health Care Innovations Exchange Website contains more than 650 searchable innovations and 1,625 searchable QualityTools. In addition, the website showcases a Quality Tool section that links to a website called Limited. Limited has compiled more than 17,000 algorithms (scales, tools, assessments, scoring systems, etc.) for the evaluation, treatment, and management of health care conditions and diseases.


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Resources / Links

Agency for Healthcare Research and Quality (AHRQ)

American Academy of Health Physics (AAHP)

American Association of Medical Administrators (AAMA)

American Association of Medical Dosimetrists (AAMD)

American Association for Medical Imaging Management (AHRA)

American Association of Medical Physicists of India (AMPI)

American Association of Physicists in Medicine (AAPM)

American Brachytherapy Society (ABS)

American Cancer Society (ACS)

American College of Radiology (ACR)

American College of Radiation Oncology (ACRO)

American Institute for Cancer Research (AICR)

American Medical Association (AMA)

American Registry of Radiologic Technologists (ARRT)

American Roentgen Ray Society (ARRS)

American Society of Clinical Oncology (ASCO)

American Society of Radiation Oncology (ASTRO)

American Society of Radiologic Technologists (ASRT)

Association of Community Cancer Centers (ACCC)

Australasian College of Physical Scientists & Engineers in Medicine (ACPSEM)

BMJ Quality & Safety (BMJ)

British Institute of Radiology (BIR)

Canadian Association of Medical Radiation Technologists (CAMRT)

Canadian College of Physicists in Medicine (CCPM)

Conference of Radiation Control Program Directors (CRCPD)

Council on Ionizing Radiation Measurements and Standards (CIRMS)

Eastern Cooperative Oncology Group (ECOG)

European Organisation for Research and Treatment of Cancer (EORTC)

European Federation of Organizations for Medical Physics (EFOMP)

European Society for Therapeutic Radiology and Oncology (ESTRO)

Health Physics Society (HPS)

U.K. Health Protection Agency (HPA)

U.K. Medicines and Healthcare Products Regulatory Agency (MHRA)

U.S. Drug and Food Administration (FDA)

U.S. Nuclear Regulatory Commission (NRC)

Institute of Physics and Engineering in Medicine (IPEM)

International Atomic Energy Agency (IAEA)

International Commission on Radiological Protection (ICRP)

International Commission on Radiation Units & Measurements (ICRU)

International Organization of Medical Physics (IOMP)

International Radiation and Health Physics (IRHP)

International Radiation Protection Association (IRPA)

National Academy of State Health Policy (NASHP)

National Comprehensive Cancer Network (NCCN)

National Patient Safety Agency (NPSA)

National Patient Safety Foundation (NPSF)

Oncology Nursing Society (ONS)

Othea Relir (RELIR)

Patient Safety Authority - Commonwealth of Pennsylvania (PSA)

Radiology Business Management Association (RBMA)

Radiological Physics Center (RPC)

Radiological Society of North America (RSNA)

Radiation Therapy Oncology Group (RTOG)

Royal College of Radiologists (RCR)

Society of Interventional Radiology (SIR)

Society of Radiation Oncology Administrators (SROA)

The Joint Commission (JCAHO)

The Leapfrog Group (TLFG)

United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR)

World Health Organization (WHO)