Health information exchange and patient safety
David C. Kaelber, David W. Bates
Journal of Biomedical Informatics 40 (2007) S40-S-45.
- 1 Introduction:
- 2 HIE and increased patient safety:
- 3 HIE and decreased patient safety:
- 4 Commentary:
- 5 Health information exchange and patient safety
- 6 A. Health information exchange and increased patient safety
- 7 B. Health information exchange and decreased patient safety
- 8 C. Standards for health information exchange and patient safety
- 9 D. Completeness of information for health information exchange and patient safety
- 10 Conclusions
- 11 Strength and limitation
- 12 Comments
Health information exchange (HIE) has the potential to enhance patient safety by providing a more complete clinical picture of the patient. It is estimated that up to 18% of patient safety errors occur because the appropriate information was not available at the time the medication decision was made. Up to 30% – 70% of the 770,000 adverse drug events (ADEs) that occur each year may be preventable.
HIE and increased patient safety:
Improved patient safety may occur through a variety of mechanisms.
- Improved medications information processing may decrease the current rate of ADEs that occur in 5-15% of therapeutic drug courses through:
- Drug-allergy information, since up to 30% of people mention a drug allergy and up to 10% of ADEs involve allergic reactions.
- Drug-dose information because dosing errors are the most common type of errors, accounting for up to 60% of prescribing errors. These checks can involve the individual dose, dose frequency, and total duration, or advance to patient-specific information like age, weight, and creatinine clearance.
- Drug-drug information can be most effective if all of a patient’s medications are known. This can include checking a new medication against the old medications for interactions, checking duplication of pharmacological class, and alerting providers to add another drug with the new one to enhance safety.
- Drug-diagnosis information takes into account medical conditions. The British National Formulary shows approximately 1500 contraindications between drugs/drug groups and various morbidities and clinical states.
- Drug-gene information, although not currently feasible, will almost certainly become more important as gene analysis and pharmacogenomics becomes more developed.
- Improved laboratory information processing will help to ensure that indicated lab testing is ordered and guarantee that lab test results are followed up on.
- Improved radiology information processing requires health information to be exchanged between the ordering and reading physician. Appropriate follow up can also be enhanced.
- Improved communication between providers since each year each patient has about 50% of visits with a primary care provider, 40% of visits with specialists, and about 10% of visits with emergency departments. Patient hand-offs have been identified as a major point of breakdown in patient safety.
- Improved communication between provider and patient including correcting errors in the medical history, following up on test results, and reviewing medications and instructions.
- Improved public health through post-marketing surveillance, infectious disease surveillance, biohazard and environmental exposure surveillance.
HIE and decreased patient safety:
It is important to remember that health information technology can decrease patient safety if implemented poorly. HIE could reduce patient safety if the wrong patient’s data were presented to the provider, or if there were errors translating from one system to another. Also, if a patient opts out of HIE providers may not realize they lack critical information.
This paper discusses the potential for safety benefits from HIE. Much of the discussion focuses on reducing ADEs. They list several different types of ADEs, including drug-allergy, drug-dose, drug-drug, drug-diagnosis, and the future potential to reduce drug-gene interactions. They also discuss improved lab and radiology reporting and improved communication between providers, patients and public health officials. Shapiro, et al, in a recent survey of New York City ER physicians found that 63% felt that HIE would help at least 25% of their patients.(1) Most (85%) felt barriers to obtaining information were too high, taking 66 minutes on average, and failing half the time. Simply having HIE by itself will not solve ADEs, however. It will need to be integrated with CPOE and decision support in EHRs to achieve the maximum benefit. There will also need to be careful consideration of what alerts are presented to physicians to avoid alert fatigue.
1 Shapiro JS, Kannry J, Kushniruk AW, Kuperman G. Emergency Physicians’ Perceptions of Health Information Exchange. J Am Med Inform Assoc. 2007;14:700-705.
Health information exchange and patient safety
David C. Kaelber, David W. Bates
One of the most promising advantages for health information exchange (HIE) is improved patient safety. Up to 18% of the patient safety errors generally and as many as 70% of adverse drug events could be eliminated if the right information about the right patient available at the right time. The authors discuss a variety of areas in which HIE can impact patient safety. They also briefly discuss HIE and decreased patient safety as well as standards and completeness of information for HIE and patient safety.
A. Health information exchange and increased patient safety
1. Improved medication information processing The authors divide HIE’s impact on medication information processing into five subsections
1.1. Drug-allergy information processing This involves checking drugs against known patient-specific drug allergies before the drugs are given to the patient.
1.2. Drug–dose information processing (1) Being sure that the individual dose, dosing frequency, and total duration of medication fall within accepted general standards. (2) taking into account patient specific information such as patient age (geriatric dosing), weight (pediatric dosing), and creatinine clearance (renal dosing).
1.3. Drug–drug information processing (1) Adding an additional medication(s) to a patient’s other medications. (2) Duplicate pharmacological class checking. (3) When one medication is being added that could indicate the addition of another medication for improved patient safety.
1.4. Drug-diagnosis information processing. (1) Taking into account medical conditions and contraindications that would affect drug dosing or administration at all. (2) Checking if the drug being prescribed is indicated for any of a patient’s diagnoses. This would help eliminate inappropriate sound-alike/look-alike medications from being prescribed such as clonidine and klonopine.
1.5. Drug–gene information processing. As gene analysis and pharamocogenomics becomes more developed, the ability to interchange drug information and patient-specific genomic information will become increasing important for patient safety.
2. Improved laboratory information processing (1) Helping to ensure that indicated lab testing is ordered (2) helping to guarantee that lab test results (especially abnormal results) are appropriately followed up on. HIE is particularly critical in this process in this era of few in-office tests, many ‘‘send-out’’ tests, and numerous independent laboratories.
3. Improved radiology information processingTypically the provider ordering an imaging study is different from the provider interpreting the imaging study. Therefore, health information has to be exchanged between these two health professionals for the radiology study to electively ordered, interpreted, and to ensure appropriate follow-up of abnormal radiology findings.
4. Improved communication among providers When different primary care providers and/or subspecialists are managing different medical issues, effective information sharing is critical.
5. Improved communication between patients and providersExamples include patients checking PHRs for errors in their medical history, adding additional valuable information into their medical records, following up on their own test results, reviewing medications and other healthcare instructions, and being able to communicate more quickly with healthcare providers when they think their safety may be at risk. PHRs may also allow providers to more quickly and more accurately provide information to their patients, which should improve patient safety.
6. Improved public health information processingA rapidly growing area of HIE is public health informatics. Patient safety could be greatly enhanced through this growth. Opportunities for improved patient safety in this area include post-marketing drug surveillance, infectious disease surveillance, biohazard surveillance, and environmental exposure surveillance.
B. Health information exchange and decreased patient safety
Increasing the level of HIE could reduce patient safety in a variety of ways, for example, if incorrect patient-specific information were made available to providers, if one patient’s information was believed to be that of another, if there were errors in translating information between one system and others or if implementation of HIE slowed systems to a significant degree, since delays can affect safety. Those who are evaluating HIE should be alert to these and other unintended consequences of implementation of HIE.
C. Standards for health information exchange and patient safety
For robust, efficient HIE, standards must be developed dictating the type and content of information to be exchanged. A prototypical example of this is the near ubiquitous proliferation of PACS (Picture Archive and Communication Systems).
D. Completeness of information for health information exchange and patient safety
Another challenge is the completeness of the HIE in order to gain the maximum benefits.
As more and more health care information becomes digital, the potential for HIE to improve patient safety will grow, and it is already robust. One challenge will be to develop healthcare systems capable of processing and utilizing the dramatic increase in information. Only then will the potential of improved patient safety through enhanced HIE be realized because we will have increased the percent age of time that the right information is presented to the right person at the right time so that the right healthcare decision can be made.
Strength and limitation
As the authors discuss the possible areas where HIE can improve patient safety they do this taking into account the most basic features at first then discuss other advanced features that may be achieved as the HIE and HIT become more developed. However they didn’t discuss how we cloud evaluate the effectiveness of the HIE in these areas. Also they didn’t give much details upon the role of HIE in the public heath although it is a main and huge area where the HIE can help in improving the patient safety.
Reviewed by Ahmed Mahmoud.
Kaelber DC, Bates DW. Health Information Exchange and Patient Safety. Journal of Biomedical Informatics. 2007 Dec;40(6 Suppl): S40-5. Epub2007
Kaelber and Bates cite IOM's 2000 Report To Err is Human which underscores the high number of patient injuries that are iatrogenic. The authors state that patient safety is compromised when the right information is unavailable to the right person at the right time and that these gaps in information are not uncommon in the US healthcare system.
A two dimensional model (who is involved in the exchange and what is being exchanged) is used to illustrate that the value of health information exchange (HIE) is optimized when more people and more information are involved.
The authors identify six different ways of improving patient safety:
Improved medication information processing which is further subdivided into
- Drug-allergy information processing
- Drug-dose information processing
- Drug-drug information processing
- Drug-diagnosis information processing
- Drug-gene information processing
- Improved laboratory information processing
- Improved radiology information processing
- Improved communication among providers
- Improved communication between patients and providers
- Improved public health information processing
The authors acknowledge that while there is substantial evidence of health information technology (HIT) leading to improved patient safety some studies have yielded antithetical results but they point out that these did not look at HIE explicitly. Nevertheless the authors acknowledge four ways increasing HIE can lead to adverse outcomes for patients including the exchange of incorrect patient-specific information; one patient's information being mistaken for that of another; inaccuracies when translating information from one system to another; significant slowing in systems which may occur during HIE implementation.
Kaelber and Bates state that standards for the type and content of information to be exchanged are necessary prerequisites for efficient HIE. They argue that the widespread use and acceptance of PACS (Picture Archive and Communication Systems) is representative of the benefits that can occur with standardization.
Another difficulty highlighted by the authors is lack of completeness of the HIE; only some information may be exchanged unknown to the user and not everyone's information is being exchanged (e.g., paper records, patients opting out of HIE networks.) They argue that at this time there are measures in place to deal with these situations but these may not continue and consequently in those situations where inadequate information is being exchanged patient safety is decreased.
The authors state that a necessary condition for HIE to improve patient safety is the development of systems with the ability to process and utilize the large increase in digital information.
The authors make a cogent argument that HIE can improve patient safety. In doing so they present a well-balanced discussion by acknowledging some of the challenges of HIE as well as occasions in which HIE can lead to decreased patient safety.