Physicians are disturbed when patient care is put at risk due to a problem caused by their use of an electronic health record (EHR). Although they will generally tolerate the situation when their reported problem is effectively managed in a transparent manner, there are a number of situations that engender scorn for their vendor. The most common scorn-generating situation is when they feel that the patient safety issue they reported has not received a high enough priority from their vendor. These situations should, and often do, resolve when the doctor and vendor communicate a clear understanding of the problem and circumstances.
But it is another situation that I think is much more frustrating. A physician’s expectation is that EHR vendors respond to patient safety issues in the same manner physicians respond to adverse medical events. Physicians engage in peer review activities to not only analyze and resolve a specific adverse event, but also determine a plan that reduces the risk of the adverse event happening again. The most common peer review activities provide legal protections from discovery which promotes transparency and more effective management of the problem. Physicians analogously expect EHR vendors to not only fix their problem, but also to transparently fix it for all other physicians using their product. This puts EHR vendors in a quandary because the legal protections of peer review activities extended to physicians are not extended to EHR vendors.
Resolving this problem will require assistance from the federal and state governments. Along those lines the Office of the National Coordinator for Health Information Technology (ONC) published a Health IT Safety Plan on December 21, 2012, and is accepting public comments on it until February 4, 2013. I believe the most important aspect of this plan is the development and use of patient safety organizations (PSOs) to identify, aggregate, and analyze health IT safety events and hazard reports.
The aviation industry continually improves passenger safety by engaging pilots in self-reporting of errors and dangerous conditions through an offer of immunity from sanctions. The federal Patient Safety Act of 2005 provides an analogous environment allowing physicians in the outpatient setting to voluntarily report and share quality and patient safety information to AHRQ-certified PSOs without fear of legal discovery. Most physicians are familiar with the secure nature of communications when they are involved in hospital quality improvement activities. The information, documents, discussions and committee reports generated under the hospital’s umbrella of quality programs are held confidential and privileged. Privileged communications cannot be disclosed and used in medical litigation without consent. PSOs offer an analogous umbrella of protection for physicians in the ambulatory setting. Physicians may voluntarily report patient safety issues or quality data from their outpatient practices to a PSO on a privileged and confidential basis. The PSO can aggregate and analyze information from multiple physicians and healthcare entities to help identify, prioritize and reduce hazards that impede quality care.
The legal protections offered to physicians through PSOs are not currently extended to EHR vendors. They should be, and I will endorse that change in my comments to ONC’s Health IT Safety Plan. But even without this change there are ways for EHR vendors to safely engage with PSOs today. Let’s consider one such scenario:
Fictional scenario: Community physicians and several EHR vendors are associated with the same patient safety organization (PSO). Dr. X is one of the physician members and his EHR vendor, VendorZ, is an analytical contractor with the PSO. After entering a digoxin dose in his EHR’s Medication Reconciliation screen, Dr. X discovered that the dose displays with a misplaced decimal point on the Medication History screen. He reports this dangerous dosing error to his PSO as a patient safety issue. The PSO notifies VendorZ. VendorZ begins working with Dr. X’s office to resolve the issue. Because VendorZ is an analytical contractor with the PSO to which this patient safety issue was reported, the reported problem, analyses, results and recommendations are confidential and privileged. When a solution is identified, there is no legal threat that disincentivizes the PSO or VendorZ to withhold this known problem and solution from other physicians in the PSO who use the same EHR. The PSO notifies all of those physicians who are members of the PSO and proactive work is done to prevent this same problem from harming patients in other practices.
EHR vendors are not inclined to openly discuss EHR problems when there is the threat of litigation against them for doing so, similar to fears physicians have with discussions of their own medical errors. But this fictional scenario exemplifies one plausible way for EHR vendors and physicians to collaborate on health IT risks today under the protective umbrella of PSOs.
As stewards of safe, quality care physicians should have a basic understanding of PSOs and carefully consider opportunities that arise to engage with a PSO on initiatives to improve outpatient care in their community. EHR vendors should demonstrate a similar stewardship by helping educate physicians about PSOs and engaging with physicians through PSOs to improve the safety of their EHR products.