1. Safety Task Force June 13, 2014

2. Task Force Members NameOrganization Members David Bates, chair Brigham and Women’s Hospital & Partners Peggy BinzerAlliance for Quality Improvement and Patient Safety Tejal Gandhi National Patient Safety Organization Mary Beth Navarra-SirioMcKesson Corporation Pau TangPalo Alto Medical Foundation Toby SamoAllscripts Steven StackAmerican Medical Association Marisa WilsonJohns Hopkins University Ex-Officio Members Jodi DanielONC Jeannie ScottDepartment of Veterans Affairs Jon WhiteAHRQ 16/13/2014

3. Meetings Task Thursday, May 29 9:00-10:00 Introductory Meeting Define scope Monday, June 9 11:30-1:30 Review of last meeting and next steps Questions for input Friday, Jun 13 10:00-12:00 Presentations David L. Mayer, NTSB Bill Munier, AHRQ Jeanie Scott, VHA Ronni Solomon, ECRI Monday, June 23 9:00-11:00 EHRA presentation Prep for final presentation Monday, July 7 11:30-1:30 Final presentation review and wrap-up Tuesday, July 8Report to HITPC 26/13/2014

4. U.S. National Transportation Safety Board (NTSB) David L. Mayer Managing Director 36/13/2014

5. Agency for Healthcare Research and Quality (AHRQ) William B Munier, MD Director, Patient Safety Organization Program Center for Quality Improvement and Patient Safety 46/13/2014

6. Veterans Health Administration (VHA) Jeanie Scott, Director of Informatics Patient Safety VHA Office of Informatics and Analytics/Health Informatics 56/13/2014

7. VETERANS HEALTH ADMINISTRATION MODEL PRESENTATION H EALTH I NFORMATION T ECHNOLOGY (HIT) S AFETY : Veterans Health Administration (VHA) Jeanie Scott, CPHIMS Informatics Patient Safety Health Informatics Office of Informatics and Analytics Department of Veterans Affairs HIT Policy Committee Safety Task Force – Model Presentation June 13,2014 6

8. VETERANS HEALTH ADMINISTRATION Veterans Health Information Systems and Technology Architecture (VistA) An integrated suite of Health Information Technology Systems used across care settings including: Electronic Health Record (EHR) Imaging Medication Administration Personal Health Records Data Sharing with and beyond VHA Much more – Administrative also… 7

9. VETERANS HEALTH ADMINISTRATION History of VA’s EHR 1977 – 1982 – Period of Central Control vs. Decentralized Clinical Innovation 1982 – Decentralized development strategy endorsed 1983: 25 sites: outpatient pharmacy, ADT*/scheduling 1985: 120 sites: Added lab, inpatient pharmacy, radiology 1989: 120 sites: Added eight additional packages 1990 – VistA Imaging 1994 – VistA Rad 1998 – Computerized Patient Record System (CPRS) 2000 – Bar Code Medication Administration (BCMA) 2007 – Indian Health Service deploys VistA Imaging *Admission/Discharge/Transfer (Registration) 8

10. VETERANS HEALTH ADMINISTRATION VistA Recognition More than 30 years experience developing medical IT solutions 2011 Harvard University Innovations in American Government Award 2008 “Top 100” CIO Award 2011 Toward the Electronic Patient Record (TEPR), 1 st place, Personal Health Record for My HealtheVet – VA’s personal health record 2010 Government Technology Leadership award for VA’s BCMA program 2013 Most Wired Award Built in partnership with clinicians, allied health and health information management professionals key to successful development and adoption. 9

11. VETERANS HEALTH ADMINISTRATION VistA VistA includes many components to deliver high-quality health care to our nation’s Veterans, including: 10 CPRS VistA Imaging BCMA Personal Health Record - My HealtheVet

12. VETERANS HEALTH ADMINISTRATION CPRS Used throughout the VHA in all health care settings (inpatient, outpatient, long-term care) to deliver an integrated record covering all aspects of patient care and treatment 11 Key Features: Clinical Decision Support Documentation Clinical Reminders Remote Data Retrieval

13. VETERANS HEALTH ADMINISTRATION BCMA BCMA virtually eliminates errors at the point of administration 12 1994 – VA was one of the first health care organizations to develop BCMA technology to improve patient safety 1999 – Deployed to all VA Medical Centers (60,000 beds) 2003 – 100% of all VA wards documenting medication administration using BCMA 2010 - >2.8 million bar code scans observed since inception

14. VETERANS HEALTH ADMINISTRATION My HealtheVet A personal My HealtheVet account provides Veterans with 24/7 online access to a variety of tools to manage their health care. 13 Communicate with participating VA Patient Aligned Care Team members View VA appointments and health information Refill VA prescriptions Download and share personal health record via the Blue Button

15. VETERANS HEALTH ADMINISTRATION Evolving…. Commercial Products Internal Development Mobile 14

16. VETERANS HEALTH ADMINISTRATION VA’s HIT Safety Program The VA’s Informatics Patient Safety Office analyzes HIT–related events/concerns that pose a risk to patient safety 15 Software Development Lifecycle Analysis Testing processes Deployment strategies Implementation practices Reporting and analysis of close calls

17. VETERANS HEALTH ADMINISTRATION Identification and Communication Medication Ordering errors (LASA) - the software will auto-fill the drug name once three letters are typed. This inserts the first drug on the list with these three letters Patient Identification Catastrophic Edits o Modifications to software o Procedure guidance ((Internal handbook) Alerts/Advisories/Guidance documents o Order Check National Term File Mapping example o Deployment strategies Mobile Apps – Developing an Inspection Review Process – “Identifying Latent Design Issues in Mobile Products to Prevent Patient Harm” - March 2014 Human Factors and Ergonomics Symposium 16

18. VETERANS HEALTH ADMINISTRATION Education/Awareness across Multiple Domains of Interest 17 Risks Associated with the Design of Electronic Medical Records -Virginia Chapter of the American Society for Healthcare Risk Management – Spring Program May 2008 Application of Human Factors Engineering Best Practices to the Redesign of a Laboratory Information Display – May 2011 National Patient Safety Foundation conference Risks to Patient Due to Incorrect Patient Record Selection – March 2013 Human Factors and Ergonomics Symposium Product Vendors requests for evaluation techniques – influence external partners.

19. VETERANS HEALTH ADMINISTRATION Questions? Contact Information: Jeanie Scott (Jeanie.Scott@va.gov)Jeanie.Scott@va.gov 18

20. ECRI Institute Ronni P. Solomon, J.D. Executive Vice President and General Counsel 6/13/201419

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