4/4/2015 Office of the National Coordinator for Health Information Technology 1 Lecture, University of Lille (7 December 1854) Louis Pasteur Dans les champs de l'observation le hasard ne favorise que les esprits préparés.

David R. Hunt, MD, FACS Medical Director, Health IT Adoption & Patient Safety ONC, Office of the Chief Medical Officer ONC Perspective on Safety: A Moment Between Reason & Risk

David R. Hunt, MD, FACS I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this activity I do not intend to discuss an unapproved/investigative use of a commercial product/device

4 Use Health IT to Make All Care Safer Improve the Safety and Safe Use of Health IT Goals:

“Doubt is uncomfortable, but certainty is ridiculous… From the depth of our profound ignorance, let us do our best;…” -- Voltaire Letter to Frederick William, Prince of Prussia Ferney, November 28, 1770

perspective 4/4/2015 Office of the National Coordinator for Health Information Technology 6 n. [L. propspectus – view]: 1 a. representing the spatial relation of objects as they might appear to the eye b. adjusting the apparent sources of sound into a natural and integrated whole 2 a. the interrelation in which a subject or its parts are mentally viewed b. the capacity to view things in their true relations or relative importance 3 a. a visible scene; esp: one giving a distinctive impression of distance

4/4/2015 Office of the National Coordinator for Health Information Technology 7 perspective

4/4/2015 Office of the National Coordinator for Health Information Technology 8 perspective

William Osler, M.D. (1849 – 1919) “In no profession does culture count for so much as in medicine…” AEQUANIMITAS Farewell Address University of Penn., 1889

safe·ty: n. (sāf’tē), [L. salvus ] : the quality or condition of being free from harm, injury, or loss

Patient Safety: the condition or act of freeing patients from the risk of harm, injury, or loss inherent from their interaction with the health care delivery system independent of the risk of harm, injury, or loss imposed from their particular disease process

IOM Health IT & Patient Safety Report 12 Commissioned by ONC 10 Recommendations Published Nov ONC Patient Safety Plan represents a response to these recommendations

Institute of Medicine, Patient Safety: Achieving a New Standard for Care: November 2003

Claudius Galen (129 – 217) 14 “Primum non nocere.”

“As to diseases make a habit of two things - to help, or at least, to do no harm.” Epidemics I Hippocrates of Kos (ca. 460 BC – ca. 370 BC) 15

16 Quality = Help Safety = Do no harm

17 Goals Health IT to Make Care Safer Improve the Safe Use of Health IT

18 Addresses the role of health IT within HHS’s commitment to patient safety. Responds to ONC sponsored IOM Report Builds upon existing authorities Seeks to strengthen patient safety efforts across government programs and the private sector

ONC Patient Safety Action & Surveillance Plan Learning: Increasing the quantity and quality of data and knowledge about health IT safety Improving: Targeting resources and corrective actions to improve health IT safety and patient safety Leading: Promoting a culture of safety related to health IT 19

ONC Patient Safety Action & Surveillance Plan Learning: Increasing the quantity and quality of data and knowledge about health IT safety Improving: Targeting resources and corrective actions to improve health IT safety and patient safety Leading: Promoting a culture of safety related to health IT 20

Learning Make it easier for clinicians to report patient safety events Engage health IT vendors to embrace their shared responsibility Provide support to Patient Safety Organizations (PSOs) Incorporate health IT safety in post-market surveillance of through ONC-Authorized Certification Bodies (ONC-ACBs). Align CMS health and safety standards Collect data on health IT safety events Monitor health IT adverse event reports 4/4/2015 Office of the National Coordinator for Health Information Technology 21

ONC Patient Safety Action & Surveillance Plan Learning: Increasing the quantity and quality of data and knowledge about health IT safety Improving: Targeting resources and corrective actions to improve health IT safety and patient safety Leading: Promoting a culture of safety related to health IT 22

Improving Use Meaningful Use to improve patient safety Incorporate safety into certification Support research and development of testing, user tools, and best practices related to health IT safety and its safe use. Incorporate health IT safety into medical education Investigate and take corrective action, when necessary. 4/4/2015 Office of the National Coordinator for Health Information Technology 23

ONC Patient Safety Action & Surveillance Plan Learning: Increasing the quantity and quality of data and knowledge about health IT safety Improving: Targeting resources and corrective actions to improve health IT safety and patient safety Leading: Promoting a culture of safety related to health IT 24

Leading Develop health IT safety priority areas Publish a report on a strategy and recommendations Establish an ONC Safety Program Encourage state governments to incorporate health IT into their patient safety oversight programs. Encourage private sector leadership and shared responsibility for health IT patient safety. 4/4/2015 Office of the National Coordinator for Health Information Technology 25

James Reason “We cannot change the human condition, but we can change the conditions under which humans work.” Human error: models and management BMJ 2000; 320:

William Osler, M.D. (1849 – 1919) “The average physician wastes fifty to sixty per cent of his time in going from place to place or in the repetition of uninstructive details of practice.” THE EARLY LIFE OF SIR WILLIAM OSLER. Bulletin No. Ix of The International Association Of Medical Museums And Journal Of Technical Methods. Montreal: Privately Printed, 1926:143

4/4/2015 Office of the National Coordinator for Health Information Technology 28 Lecture, University of Lille (7 December 1854) Louis Pasteur In the field of observation, chance favors the prepared mind. Dans les champs de l'observation le hasard ne favorise que les esprits préparés.

mo·ment (mō י mənt) n. [ME. < L. momentum, movement, impulse, brief space of time, importance < movimentum < movere, to MOVE] 1. an indefinitely brief period of time 2. a definite point in time 3. a brief time of being important 4. importance; consequence 5. Mech. the tendency to cause motion about a point or axis

Archimedes of Syracuse ( BC) Mech. the tendency to cause motion about a point or axis

“Give me where to stand and I will move the world.” Δός μοι π ᾶ στ ῶ κα ὶ τ ὰ ν γ ᾶ ν κινάσω Pappus of Alexandria, Synagoge, Book VIII, c. AD 340. Archimedes of Syracuse ( BC)

Thank You Contact Information 32