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Patient Safety and Health Information Technology E-Newsletter

September 4, 2009, Issue No. 55

Quote of the Month

"The goal of assuring an electronic health record for every American is daunting. We at the Office of the National Coordinator for Health Information Technology do not pretend otherwise. We know this will be hard for some clinicians and hospitals, and we stand ready to help with resources provided by the Congress and the Administration." (For more details, go to item no.1.)

—David Blumenthal, M.D., M.P.P., National Coordinator for Health Information Technology

Today's Headlines:

AHRQ Health Information Technology (Health IT) News

National Coordinator for Health IT stresses importance of electronic health record systems
New resource discusses the benefits of electronic medical record systems
New report highlights lessons from Regional Health Information Organizations
AHRQ in the health IT professional literature—some useful citations

AHRQ Patient Safety News:

AHRQ launches new health care-associated infections resource Web page
Revised Common Formats (Version 1.0) now available for Patient Safety Organizations
New resources to advance quality and safety in nursing care
Register now for conference on "Diagnostic Errors in Medicine" on October 21-22
Latest issue of WebM&M is available online
AHRQ in the patient safety professional literature—some useful citations

AHRQ Issues Notice of Intent for Comparative Effectiveness Grants and Contracts Under the American Recovery and Reinvestment Act

AHRQ Issues Updated Individual Awards for Postdoctoral Fellows Program Funding Announcement

AHRQ Health IT News:

1. National Coordinator for Health IT Stresses Importance of Electronic Health Record Systems

National Coordinator for Health Information Technology, David Blumenthal, M.D., M.P.P., recently issued a message on the importance of electronic health records and the vital role they play in transforming health care. A nationwide electronic health information exchange will provide the best opportunity for each patient to receive optimal care, he noted. The technology will make patients' complete medical information securely and reliably available to health care providers where and when it is needed—when clinician and patient are together facing medical decisions that can make a lasting difference. Better, faster, more reliable and efficient care also ultimately reduces system-wide costs by delivering results that help to avoid expensive or prolonged hospitalization from delayed or ineffective treatment, avert costly and sometimes fatal adverse events and unnecessary procedures, and can help to eliminate the onset of disease by better informed management of each patient's health, according to Dr. Blumenthal. Select to access his entire message on the Office of the National Coordinator for Health Information's Web site.

2. New Resource Discusses the Benefits of Electronic Medical Record Systems

AHRQ has released new information on electronic medical record (EMR) systems—electronic records of health-related information that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization. EMRs have the potential to provide substantial benefits to physicians, clinic practices, and health care organizations by facilitating workflow and improving the quality of patient care and patient safety. Select to access the resource and for information on other key topics relevant to health IT.

3. New Report Highlights Lessons from Regional Health Information Organizations

AHRQ has released a new report that summarizes key findings from AHRQ-funded State and Regional Demonstration projects and other Regional Health Information Organizations (RHIOs). The report, Liability Coverage for Regional Health Information Organizations (PDF File, Plugin Software Help), focuses on lessons learned from the field on the key considerations, issues, and challenges associated with liability insurance for RHIOs.

4. AHRQ in the Health IT Professional Literature—Some Useful Citations

We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. If you are having problems accessing the abstracts because of firewalls or specific settings on your individual computer systems, you should ask your technical support staff for possible remedies.

Harris LT, Haneuse SJ, Martin DP, et al. Diabetes quality of care and outpatient utilization associated with electronic patient-provider messaging: a cross-sectional analysis. Diabetes Care 2009 Jul; 32(7):1182-7. Select to access the abstract.

Poon EG, Cusack CM, McGowan JJ. Common Issues with Evaluating Healthcare Information Technology: Observations from the National Resource Center for Healthcare Information Technology at the Agency for Healthcare Research and Quality. J Am Med Inform Assoc 2009 Jun 30; (Epub):1-21. Select to access the abstract.

Terry AL, Giles G, Brown JB, et al. Adoption of electronic medical records in family practice: the providers' perspective. Fam Med 2009 Jul-Aug; 41(7):508-12. Select to access the abstract.

Wakefield DS, Brokel J, Ward MM, Schwichtenberg T, Groath D, Kolb M, Davis JW, Crandall D. An exploratory study measuring verbal order content and context. Qual Saf Health Care. 2009 Jun;18(3):169-73. Select to access the abstract.

AHRQ Patient Safety News:

5. AHRQ Launches New Health Care-Associated Infections Resource Web Page

AHRQ has launched a new Web page that features research initiatives and resources on health care-associated infections (HAIs) for clinicians and consumers. Information from AHRQ, Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services' (HHS) Office of Public Health and Science's National Action Plan on HAIs, and other resources focused on preventing and reducing HAIs are listed. Resources for health care providers, including links to the Michigan Keystone Project that features the Comprehensive Unit-based Safety Program for reducing infections and the Johns Hopkins central line insertion care team checklist, are featured. Other resources from the World Health Organization, the American Health Quality Association, the Association for Professionals in Infection Control and Epidemiology, and the Society for Healthcare Epidemiology of America are featured. We also feature links to relevant AHRQ consumer advice columns, press releases, and Congressional hearings and testimony. Select to access the new AHRQ HAI Web page.

6. Revised Common Formats (Version 1.0) Now Available for Patient Safety Organizations

AHRQ has released Version 1.0 of Common Formats for collecting and reporting patient safety information, including adverse events, near misses, and unsafe conditions, in the hospital setting. The revised Common Formats update Version 0.1 beta released in August 2008 that were developed by health agencies within the Federal government. Version 1.0 reflects public input from individuals, provider organizations, and healthcare associations. AHRQ contracted with the National Quality Forum (NQF) to assist with gathering comments and provide expert advice on the beta version of Common Formats. The NQF also will assist AHRQ with revisions to Version 1.0 based on users' feedback and other input. AHRQ also plans to develop Common Formats for other settings, such as nursing homes, ambulatory surgery centers, and physician and practitioner offices. Common Formats, which are authorized by the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), establish a standard language, definitions, technical requirements and reporting specifications that patient safety, quality, and risk managers, clinicians, and others can use to collect patient safety event information. Patient Safety Organizations (PSO) will use Common Formats to ensure consistency in reporting patient safety event information and allow aggregation and analysis of comparable, interoperable data at provider, PSO, and national levels. AHRQ's revised Common Formats include descriptions of patient safety events and unsafe conditions to be reported, paper forms delineating data elements to be collected for patient safety events and unsafe conditions, and an updated user's guide. AHRQ also plans to release technical specifications, including patient safety population reports, in the first quarter of 2010 that will expedite the development of software to automate the Common Formats. The revised Common Formats and accompanying user information are available at no charge through AHRQ's PSO Web site at http://www.pso.ahrq.gov/.

7. New Resources to Advance Quality and Safety in Nursing Care

The Robert Wood Johnson Foundation has released two papers on quality and safety as part of their "Charting Nursing's Future" series. One report titled "Addressing the Quality and Safety Gap—Part I: Case Studies in Transforming Hospital Nursing and Building Cultures of Safety," explores the five tenets of highly reliable organizations and includes an expert commentary by AHRQ's Kerm Henriksen, Ph.D., human factors adviser for patient safety. The second report, titled "Addressing the Quality and Safety Gap—Part II: How Nurses are Shaping, and Being Shaped by, Health Information Technologies," provides promising models of nursing-related health information technologies in several categories: electronic health records, telenursing, and bar code medication administration. The report offers news about current educational efforts to bring nursing faculty online and build awareness about how to engage practicing nurses in shaping policy.

8. Register Now for Conference on "Diagnostic Errors in Medicine" on October 21-22

Practicing clinicians, scientists, safety officers, risk managers, informatics professionals, clinical and basic investigators, educators, and trainees are invited to attend the second international conference dedicated specifically to diagnostic errors in medicine. The goal of this meeting is to improve patient safety by reducing the likelihood of diagnostic error in medicine. Minimizing diagnostic error is an essential component of safe patient care, and the conference activities are organized to summarize the current state of the field, review active research, and consider emerging ideas on the education and research agenda that should be implemented to reduce diagnostic error. The event, scheduled for October 21-22 in Los Angeles, CA, will be held in association with the annual meeting of the Society of Medical Decision Making. Both meetings are cosponsored by AHRQ. Select to register for the diagnostic errors conference.

9. Latest Issue of WebM&M is Available Online

The August issue of AHRQ WebM&M is now available online. The Perspectives on Safety section highlights how lessons from industry apply to health care. The "In Conversation With" article features Steven J. Spear, D.B.A., Massachusetts Institute of Technology and the Institute for Healthcare Improvement, Cambridge, MA, who speaks on how companies can groom excellent management that leads to market innovation and efficient problem-solving. In the accompanying perspective piece, Anita L. Tucker, D.B.A., Harvard Business School, Boston, MA, discusses workarounds and resiliency on the front lines of health care. In the Spotlight Case, "Nurse-Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care," features a commentary by Victoria Rich, Ph.D., R.N., University of Pennsylvania School of Nursing, Philadelphia, PA, discussing issues surrounding nurse staffing, patient safety, and quality of care. The second case, "Hiding in Plain Sight," features a commentary by Jeffrey M. Weinberg, M.D., Columbia University College of Physicians and Surgeons, New York, NY, discussing information about properly evaluating and managing herpes zoster. The third case, "Is the Admission Drug Dose Too Low?," features a commentary by Rainu Kaushal, M.D., and Erika Abramson, M.D., Weill Cornell Medical College, New York, NY, discussing key issues in medication safety and assessing therapeutic dose levels for hospitalized patients. Physicians and nurses can receive free CME, CEU, or trainee certification by taking the Spotlight Quiz. You can easily share AHRQ WebM&M cases by using the "e-mail a colleague" feature.

10. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

Alexander DC, Bundy DG, Shore AD, et al. Cardiovascular medication errors in children. Pediatrics 2009 Jul; 124(1):324-32. Select to access the abstract.

Casalino LP, Dunham D, Chin MH, Bielang R, Kistner EO, Karrison TG, Ong MK, Sarkar U, McLaughlin MA, Meltzer DO. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med 2009 Jun 22;169(12):1123-9. Select to access the abstract.

Gallagher TH. A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. JAMA 2009 Aug 12;302(6):669-77.Select to access the abstract.

AHRQ Issues Notice of Intent for Comparative Effectiveness Grants and Contracts Under the American Recovery and Reinvestment Act

AHRQ has issued a Notice of Intent to publish grant and contract solicitations for comparative effectiveness research projects with $300 million in funds from the American Recovery and Reinvestment Act (ARRA). AHRQ anticipates grant and contract solicitations to be published beginning in fall 2009 with awards starting in spring 2010. Until the solicitations are published, AHRQ cannot provide additional information on their contents. In the meantime, interested parties may sign up to receive e-mail updates by clicking on the red envelope at the top of AHRQ's Effective Health Care program Web site.

AHRQ Issues Updated Individual Awards for Postdoctoral Fellows Program Funding Announcement

AHRQ has issued an updated funding opportunity announcement (FOA) that announces AHRQ's intent to continue its Individual Awards for Postdoctoral Fellows (F32) program. It also highlights AHRQ's particular interest in applications that focus on identified priority areas in one of the six AHRQ portfolios: value, prevention/care management, health information technology, comparative effectiveness, patient safety, and innovations and emerging issues. The FOA also provides details regarding the transition of grant applications from paper to electronic submission. Select to access the updated program announcement.

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Current as of September 2009

Internet Citation:

Patient Safety and Health Information Technology E-Newsletter. September 4, 2009, Issue No. 55. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ptsnews/ptsnews55.htm