CTL director dissents from IOM report on HIT and patient safety.
Richard I Cook, Director of CTL, was a member of an Institute of Medicine committee examining the impact of health IT on patient safety. He wrote a dissenting opinion which was published along with the report on November 8, 2011. The full report is available on the National Academy of Sciences website for free download.
At issue is the safety of current health IT. It is clear that current health IT, particularly electronic medical records (EMRs) used in many hospitals and clinics, poses a serious threat to patient safety. The use of these systems has led to harm to patients as demonstrated by the case cited in the dissent. The failure by the HIT industry and the government to anticipate, acknowledge, and address the safety of these medical devices has crippled the development of effective health IT. This makes it virtually certain that U.S. healthcare will fail to acquire the economic and safety benefits of health IT for the foreseeable future.
The CTL website publications collectively address the underlying problem with current generation health IT and provide a roadmap for understanding technical work and developing effective, useful HIT that improves patient safety.
Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method
A recent article by Greenhalgh et al. provides a detailed review of the evidence regarding the value of electronic patient records. It is available directly from the Milbank Quarterly website.
Medicare Payment Changes
Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates (CMS-1390-F), published 19 August 2008, describes adjustments to 2009 Medicare compensation including acute care organizations that are teaching hospitals, serve low income patients, and handle unusually costly "outlier" cases. (more…)
Building Resilient Complex Systems
Ashgate Publishing's Resilience Engineering Perspectives Series now includes Remaining Sensitive to the Possibility of Failure, which compiles papers from the November 2007 2nd Symposium on Resilience Engineering in Juan-Les-Pins France. These newly-evolving concepts of resilience and resilience engineering define "success" based on the ability of organizations, groups and individuals to anticipate the changing shape of risk before failures and harm occur. Resilience Engineering: Concepts and Precepts was the first volume to explore this groundbreaking new development in safety and risk management.
The 3rd International Symposium on Resilience Engineering, held in November 2008, featured recent research and writing on resilience and engineering resilient systems.
Strasbourg Keynote Probes Adverse Event Investigation
CTL's Richard Cook gave one of two main keynote presentations at the International Conference on Health Systems Ergonomics and Patient Safety in Strasbourg, France on June 25th, 2008. His presentation, "What are we missing? Results of MEDCAS, the National Healthcare Safety Board Demonstration Project" described what a team of technically-qualified independent investigators can learn about adverse events that in-house investigations miss. His message was based on the CTL's recent "Medical Event Data Collection and Analysis Service" project funded by the VHA Health Foundation and the U.S. Food and Drug Administration.
Improving Healthcare Team Communication
CTL's Christopher Nemeth edited the recent Ashgate Publishing release Improving Healthcare Team Communication that features the work of leading researchers in healthcare communication. Their insights from 'sharp end' operator research in high-hazard sectors shed light on the performance of cognitive tasks in groups and across healthcare organizations.
"Here a cluster of the world's experts extract lessons from both domains that those who seek to improve patient safety will find fascinating and useful." --Lucian L. Leape, MD, Harvard School of Public Health, USA
Bewildered by medical equipment interfaces? You're not alone! Bruce McCall introduces the latest gizmo designed to maximize your performance through information technology. (more...)