IT and Patient Safety

Physicians have been using computers for many years to improve medical practice. Many are just now realizing that information technology can be deployed to help patient safety efforts. The results? Reduced medical errors, improved educational efforts, decreased numbers of adverse events, and better clinical outcomes.

"Doing no harm has always been a goal of our profession," says Brian Goldstein, MD, chief of staff for the University of North Carolina (UNC) Hospitals and executive associate dean for UNC School of Medicine, Chapel Hill. "But now we are trying to become more specific in how we go about using various technology tools to help us do no harm. We are adapting this philosophy to the high-tech care environment that we are increasingly working in."

What's confusing to many is that there is no silver bullet in technology -- no one tool for physicians to latch on to. And many experts now urge the industry to stop looking for one. The division of general medicine and primary care at Brigham & Women's Hospital in Boston studied the use of information technology to improve ambulatory care patient safety and recommended against the widespread adoption of any particular technology. Rather, the report called for embracing patient safety standards that would drive physicians toward various technologies.

Many choices

The information technology tools that doctors use to increase patient safety run the gamut from simple to complex. Although computerized physician order entry systems are commonly viewed as the pillars of the patient safety movement (to learn more, enter "CPOE" in the search box on this site), doctors are discovering other technologies that can bolster safety. Items as simple as e-mail and screen savers or as complex as electronic medical records, wireless devices, and specialized databases can help keep patients safe.

And while preventing medical errors is the rallying cry of many patient safety initiatives, many physician practices take a much broader view of patient safety, says Richard Rafoth, MD, associate medical director of quality at Everett Clinic, a 200-physician practice in western Washington state that includes two surgical facilities and an advanced imaging center.

"Anything I can do to prevent an adverse outcome is patient safety. It is really just a subset of quality. Just educating the patient can be considered a part of patient safety," Rafoth says.

Keep it simple

Technology to improve patient safety doesn't have to break the bank. Simply thinking of the various ways that information technology can be redeployed could produce patient safety improvements, UNC's Goldstein says.

For example, Goldstein uses e-mail and screen savers to bolster educational efforts at UNC. He routinely sends clinicians e-mail messages with safety information such as national patient safety goals from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In addition, Goldstein uses screen savers to give clinicians easy access to JCAHO's list of potentially confusing or misleading abbreviations that should be avoided in healthcare.

"Just having the information pop up in places that are close to the point of care will remind people and that will help our safety efforts significantly," he says.

Goldstein also implemented online education and testing software from Pathlore Software Corporation that helps ensure that staff members comply with required training.

For example, physicians must complete a training course before administering conscious sedation to patients. The Pathlore software can keep tabs on who has and has not completed the required training. The software keeps tallies on which staff have completed required training on blood-borne pathogens and whether they correctly answered questions about the training session.

Rethink what you have

Many physician practices have already implemented practice management and electronic medical records systems. Although most medical groups embraced these tools to increase efficiency and cut costs, some physicians are rethinking the technology and discovering many patient safety applications.

"Someone has to have a vision and demonstrate how these tools can result in an improvement in quality," says James L. Holly, MD, CEO of Southeast Texas Medical Associates in Beaumont.
Holly is leading an effort in the practice to use a practice management and electronic medical records system from NextGen Healthcare Systems to improve safety.

The most obvious way that an EMR can boost safety is by detecting potential medication errors. To detect drug interactions with a paper-based record, doctors must review the chart to see the patient's current medications and then mentally cross-reference those drugs with knowledge of any potential interactions. With an EMR, the doctor can quickly and almost seamlessly cross-check a patient's electronic chart with an electronic reference to determine if there are any potential drug-to-drug, patient allergy, or patient condition interactions.

The EMR also can help doctors provide better, more personalized treatment to patients. Family medical history stored in a patient's EMR can help physicians quickly assess specific risks such as colon, skin, or breast cancer, Holly says. In addition, the EMR can help physicians stay on top of patients' immunization needs.

Integrate your tools

Rose Rogers, the administrator at Rockoff Dermatology Center in Brookline, Mass., also is discovering how the office's practice management and EMR systems can be used to improve safety. Patient safety was not a primary concern when the practice implemented CareTracker, an online practice management and electronic medical records system from LiteHouse MD. But safety is emerging as one of the major benefits of the system.

The system's closely integrated clinical and scheduling functions help to improve patient safety by making sure that follow-up appointments don't fall through the cracks. For example, when a patient has a cancerous lesion removed and must be seen in six months, the system automatically schedules the follow-up appointment. Similarly, if a patient has a positive biopsy, the system automatically schedules a follow-up appointment.

"Our biopsies are all recorded in the system in a separate place," Rogers says. "It's a good thing because with a paper system, it is so easy to lose these biopsy results if they are just written on a piece of paper. And, if it is a positive biopsy and the patient does not get notified, you can just imagine the consequences. Imagine not notifying a patient who has melanoma. That would just be devastating."

The practice also uses the system to notify patients of drug or product recalls. If a certain ointment or lotion were recalled, Rogers could quickly find the names of patients who had purchased the product and notify them of the recall. It would be virtually impossible to pull the names in a timely manner if the information were stored on paper.

An EMR also can help physicians stay in compliance with various treatment recommendations from groups such as the American Heart Association and American Preventive Services Task Force, says Eric Poon, MD, associate physician and research scientist with Brigham & Women's Hospital.

"The system holds these guidelines and then reminds doctors to put patients on a specific drug if it is called for. Quite a few of these recommendations are typically not complied with simply because doctors don't remember," Poon says. "With the EMR, however, we have been able to demonstrate that physicians comply twice as much."

Carry information with you

Certainly, easy access to information is a boon to patient safety. Doctors are realizing that access to medication information via wireless devices can increase patient safety significantly.

Neil Natkow, DO, and CEO of PhyTrust, a Tampa, Fla.-based managed service organization that contracts with about 300 providers, says that all of his physicians use wireless devices to decrease medication errors.

The tool -- eMPOWERx, a secure, wireless Pocket PC/PCS phone -- enables doctors to access drug information at the point of care. The device allows physicians to access clinically relevant drug information, preferred drug list alternatives, and patient-specific prescription histories and drug interactions.

"Typically a doctor only knows what the patient tells them about medications," Natkow says. "Patients could be taking medications prescribed by other doctors and simply refuse or forget to tell the doctor about these meds. This device provides some type of gate keeping. It automatically tells the physician what drugs the patient is on and automatically alerts the physician if there is a problem with the drug that he is thinking of prescribing," Natkow says.

The device's user-friendly design ensures physician adoption. "Doctors reject technology that is not easy to use," says Natkow. "But this device is so convenient for doctors to use."

Address causes of errors

Although access to information at the point of care is an important element of patient safety, physician practices should also take an evaluative approach. To increase safety at Everett Clinic, Rafoth decided that the practice needed to gather as much information as possible about the events that lead up to errors or sub-par outcomes.

The practice changed its human resources policy to offer protection to staff members who reported adverse events.

"They receive a get-out-of-jail-free card," Rafoth says. "As such, they won't be so reluctant to talk about the situation that actually precipitated the mistake."

In addition to offering employees immunity, Rafoth also developed a Web-based reporting system that makes it a snap to report adverse events --  and even provides staff members with the option to remain anonymous.

"People can just go to any computer, access the site, and type in a few short lines about what happened," he says. "The simpler you can make the reporting process, the better. If it is a complicated process, people will just put it off and eventually forget about the event."

Since implementing the system a little more than a year ago, the practice has seen a sharp increase in the number of adverse events being reported. In December 2003, 27 events were reported, compared with seven reported the previous January.

Rafoth and a colleague address every reported incident -- even events that are not of a clinical nature, such as a patient tripping over a ripped carpet.

Adverse events can be organized into categories within the database, which was developed in-house at Everett. By searching the database for synergies among the various incidents, the practice can identify the root causes of problems --  and work on solutions.

Whether it is improved tracking of adverse events, better screening of patients' drug interactions, or boosting clinical training and compliance, today's information technology tools offer an increasingly wide array of effective and affordable tools for physicians. Often, medical practices can find the tools they need to make patients safer in their practice's existing information technology systems.

John McCormack can be reached at editor@physicianspractice.com.

This article originally appeared in the April 2004 issue of Physicians Practice.