Health information exchange and patient safety

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David C. Kaelber, David W. Bates

Journal of Biomedical Informatics 40 (2007) S40-S-45.

Introduction:

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.

1. Improved medications information processing may decrease the current rate of ADEs that occur in 5-15% of therapeutic drug courses through:

a. Drug-allergy information, since up to 30% of people mention a drug allergy and up to 10% of ADEs involve allergic reactions.

b. 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.

c. 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.

d. 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.

e. Drug-gene information, although not currently feasible, will almost certainly become more important as gene analysis and pharmacogenomics becomes more developed.

2. Improved laboratory information processing will help to ensure that indicated lab testing is ordered and guarantee that lab test results are followed up on.

3. Improved radiology information processing requires health information to be exchanged between the ordering and reading physician. Appropriate follow up can also be enhanced.

4. 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.

5. Improved communication between provider and patient including correcting errors in the medical history, following up on test results, and reviewing medications and instructions.

6. 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.

Commentary:

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.

Charles Laudenbach