> **The National Resource Center for Health Information Technology and
> the Patient Safety Research Coordinating Center**
>
> AHRQ 2005 Annual Patient Safety and Health
>
> Information Technology Conference: *Making the Health*
>
> *Care System Safer Through Implementation and Innovation*
>
> June 6-10, 2005  Washington, D.C.

**Conference Proceedings**

> Presented to:
>
> Agency for Healthcare Research and Quality
>
> Center for Quality Improvement and Patient Safety
>
> 540 Gaither Road
>
> Rockville, MD 20850
>
> Presented by:
>
> NORC
>
> A national organization for research at the University of Chicago
>
> 1350 Connecticut Ave, NW, Suite 500
>
> Washington, DC 20036
>
> \(202\) 223-6040

# 

# 

Table of Contents

[Introduction and Roadmap 7](#introduction-and-roadmap)

[CHAPTER ONE: 11](#chapter-one)

[PATIENT SAFETY 11](#patient-safety)

[Patient Safety in 2005: The End of the Beginning
11](#patient-safety-in-2005-the-end-of-the-beginning)

[SESSIONS AND FINDINGS 12](#sessions-and-findings)

[A. INTERSECTION OF HEALTH IT AND PATIENT SAFETY
13](#a.-the-intersection-of-health-it-and-patient-safety)

[I. Avoiding Adverse Drug Events 14](#i.-avoiding-adverse-drug-events)

[II. Using Health Information Technology (HIT) To Improve Care: Three
Clinical Examples
15](#ii.-using-health-information-technology-hit-to-improve-care-three-clinical-examples)

[III. Hidden Issues in Implementing Technology--I
16](#iii.-hidden-issues-in-implementing-technologyi)

[IV. Hidden Issues in Implementing Technology--II
17](#iv.-hidden-issues-in-implementing-technologyii)

[V. Challenges of Implementing an Electronic Health Record
18](#v.-challenges-of-implementing-an-electronic-health-record)

[B. TOOLS FOR SAVING PATIENT LIVES
19](#b.-tools-for-saving-patient-lives)

[I. Risk and Recovery 20](#i.-risk-and-recovery)

[II. Preventing Infections 21](#ii.-preventing-infections)

[III. Improving the Accuracy of Patient Identification
22](#iii.-improving-the-accuracy-of-patient-identification)

[IV. Preventing Adverse Drug Events
23](#iv.-preventing-adverse-drug-events)

[V. Improving the Safety of Cardiac Care
24](#v.-improving-the-safety-of-cardiac-care)

[C. PATIENT SAFETY ACROSS SETTINGS AND POPULATIONS
26](#c.-patient-safety-across-settings-and-populations)

[I. Hospital Care 27](#i.-hospital-care)

[II. Older Patient Care 27](#ii.-older-patient-care)

[III. Ambulatory Care 29](#iii.-ambulatory-care)

[IV. Moving the Patient Across a System of Care
30](#iv.-moving-the-patient-across-a-system-of-care)

[V. Children's Care 31](#v.-childrens-care)

[D. SYSTEMS ISSUES AND THE CLINICAL ENVIRONMENT
33](#d.-systems-issues-and-the-clinical-environment)

[I. Organizational Climate Matters: Direct and Indirect Effects on
Patient Safety
34](#i.-organizational-climate-matters-direct-and-indirect-effects-on-patient-safety)

[II. What Do Medical Errors Cost and Are System Changes Worth It?
35](#ii.-what-do-medical-errors-cost-and-are-system-changes-worth-it)

[III. Techniques for Institutionalizing a Safety Culture
36](#iii.-techniques-for-institutionalizing-a-safety-culture)

[IV. Assessing Your Health Care Environment for Safety
37](#iv.-assessing-your-health-care-environment-for-safety)

[V. Impact of Working Conditions on Patient Safety
39](#v.-impact-of-working-conditions-on-patient-safety)

[E. EDUCATION AND TRAINING FOR SAFETY
40](#e.-education-and-training-for-safety)

[I. Informing Patients and Families About Adverse Events
41](#i.-informing-patients-and-families-about-adverse-events)

[II. Does Team Training Make a Difference in Delivering Safe Care?
42](#ii.-does-team-training-make-a-difference-in-delivering-safe-care)

[III. Health Care Education Tools -- I
43](#iii.-health-care-education-tools-i)

[IV. Health Care Education Tools--II
44](#iv.-health-care-education-toolsii)

[V. Are Simulations Effective Training Tools?
45](#v.-are-simulations-effective-training-tools)

[F. USING REPORTING SYSTEMS EFFECTIVELY
47](#f.-using-reporting-systems-effectively)

[I. Using Data Systems To Identify Potential Harm -- I
48](#i.-using-data-systems-to-identify-potential-harm-i)

[II. Using Data Systems To Identify Potential Harm--II
48](#ii.-using-data-systems-to-identify-potential-harmii)

[III. Using Reporting Systems Data for Action--I
49](#iii.-using-reporting-systems-data-for-actioni)

[IV. Using Reporting Systems Data for Action--II
51](#iv.-using-reporting-systems-data-for-actionii)

[V. Using Reporting Systems To Engage Consumers in Patient Safety
52](#v.-using-reporting-systems-to-engage-consumers-in-patient-safety)

[CHAPTER TWO: 54](#chapter-two)

[PATIENT SAFETY/HEALTH INFORMATION TECHNOLOGY CROSSOVER DAY
54](#patient-safetyhealth-information-technology-crossover-day)

[Opening Remarks By Carolyn Clancy, Director, Agency for Health research
And Quality
54](#opening-remarks-by-carolyn-clancy-director-agency-for-health-research-and-quality)

[Keynote Address: Michael Leavitt, Secretary, United States Department
of Health and Human Services
55](#keynote-address-michael-leavitt-secretary-united-states-department-of-health-and-human-services)

[Keynote Address: Honorable Nancy Johnson (R-CT)
55](#keynote-address-honorable-nancy-johnson-r-ct)

[Congressional Staff Panel on Health Policy
56](#congressional-staff-panel-on-health-policy)

[Innovations in Health IT and Patient Safety
56](#innovations-in-health-it-and-patient-safety)

[Keynote: Reed Tuckson, Senior Vice President, UnitedHealth Group
57](#keynote-reed-tuckson-senior-vice-president-unitedhealth-group)

[Behind the Scenes: How the News Media Covers New Developments in
Patient Safety and Health IT
57](#behind-the-scenes-how-the-news-media-covers-new-developments-in-patient-safety-and-health-it)

[Strategic Framework for Improving Health Care Through HIT: David
Brailer, National Coordinator for Health Information Technology
58](#strategic-framework-for-improving-health-care-through-hit-david-brailer-national-coordinator-for-health-information-technology)

[CHAPTER THREE: 60](#chapter-three)

[HEALTH INFORMATION TECHNOLOGY 60](#health-information-technology)

[Health Information Technology in 2005
60](#health-information-technology-in-2005)

[SESSIONS AND FINDINGS 61](#sessions-and-findings-1)

[A. THE INTERSECTION OF HEALTH IT AND PATIENT SAFETY
62](#a.-the-intersection-of-health-it-and-patient-safety-1)

[I. Highlights of AHRQ's Patient Safety Portfolio
63](#i.-highlights-of-ahrqs-patient-safety-portfolio)

[II. Translating Health IT Into The Practice Of Patient Safety
64](#ii.-translating-health-it-into-the-practice-of-patient-safety)

[III. Improving Medication Management and Blood Product Administration
66](#iii.-improving-medication-management-and-blood-product-administration)

[IV. Ask the Experts: Patient Safety and Health IT
67](#iv.-ask-the-experts-patient-safety-and-health-it)

[B. HEALTH INFORMATION EXCHANGE 69](#b.-health-information-exchange)

[I. HIE Planning: How to Get Started
70](#i.-hie-planning-how-to-get-started)

[II. HIE Organization and Governance Approaches and Models
71](#ii.-hie-organization-and-governance-approaches-and-models)

[III. Perspectives From The Front Lines
72](#iii.-perspectives-from-the-front-lines)

[IV. Implementation and Beyond 74](#iv.-implementation-and-beyond)

[C. ASSESSING VALUE AND EVALUATING HEALTH IT
76](#c.-assessing-value-and-evaluating-health-it)

[I. Basic Study Design and Quantitative Methods
77](#i.-basic-study-design-and-quantitative-methods)

[II. Survey and Qualitative Methods for Evaluation
78](#ii.-survey-and-qualitative-methods-for-evaluation)

[III. Health It Evaluation Case Studies
79](#iii.-health-it-evaluation-case-studies)

[IV. Open Forum With Health IT Evaluation Experts
82](#iv.-open-forum-with-health-it-evaluation-experts)

[D. PUBLIC TRUST IN HEALTH INFORMATION SYSTEMS: HANDLING PRIVACY,
SECURITY AND RELATED ISSUES
83](#d.-public-trust-in-health-information-systems-handling-privacy-security-and-related-issues)

[I. HIPAA 101: Basic HIPAA Privacy and Security
84](#i.-hipaa-101-basic-hipaa-privacy-and-security)

[II. Privacy and Security: Practical Consideratons
85](#ii.-privacy-and-security-practical-consideratons)

[III. Building a Culture of Confidentiality and Security
87](#iii.-building-a-culture-of-confidentiality-and-securtiy)

[IV. Consumer Perspectives 88](#iv.-consumer-perspectives)

[E. COORDINATING CARE USING IT AND TELEHEALTH
90](#e.-coordinating-care-using-it-and-telehealth)

[I. Health IT and Pediatrics 91](#i.-health-it-and-pediatrics)

[II. Case Studies: Adoption of e-Prescribing
92](#ii.-case-studies-adoption-of-e-prescribing)

[III. Changing Clinical Practice for Telehealth
94](#iii.-changing-clinical-practice-for-telehealth)

[IV. Managing Clinical Handoffs Across IT Settings
95](#iv.-managing-clinical-handoffs-across-it-settings)

[F. HEALTH IT NUTS & BOLTS: TACKLING THE TECHNICAL ISSUES
97](#f.-health-it-nuts-bolts-tackling-the-technical-issues)

[I. Organization Redesign and Clincial Change
98](#i.-organization-redesign-and-clincial-change)

[II. Inter-institutional Data Sharing: Standards and Legal
Implications.............................99](#iii.-implementation-and-training-strategies-for-success)

[III. Implementation and Training Strategies for Success
100](#iii.-implementation-and-training-strategies-for-success)

[IV. Insights on New Technologies
101](#iv.-insights-on-new-technologies)

[G. FUNDING AND MANAGING HEALTH IT PROJECTS
103](#g.-funding-and-managing-health-it-projects)

[I. Health IT Project Management 101: Getting Started and Staying On
Track
104](#i.-health-it-project-management-101-getting-started-and-staying-on-track)

[II. Managing Health IT in the Real World: Challenges and Solutions
105](#ii.-managing-health-it-in-the-real-world-challenges-and-solutions)

[III. Funding Health IT: Government, Foundation and Payer Perspectives
106](#iii.-funding-health-it-government-foundation-and-payer-perspectives)

[IV. Mock Evaluation Panel, Health IT Implementation Projects
108](#iv.-mock-evaluation-panel-health-it-implementation-projects)

+---------------+------------------------------------------------------+
|               | # Introduction and Roadmap                           |
+---------------+------------------------------------------------------+

From June 6 -10, 2005, the Agency for Healthcare Research and Quality
(AHRQ) assembled its first joint Patient Safety and Health Information
Technology (Health IT) Annual Conference. The conference convened
researchers, federal officials, health care providers, and corporate
health care leadership to examine the degree to which the Nation has
progressed with respect to creating a high-quality, safe health care
system. The first two days of the conference focused on patient safety.
Day three served as a crossover day, featuring keynote addresses and
presentations highlighting the overlap between patient safety and health
IT. Finally, days four and five focused on health IT.

In all, conference participants engaged in 30 overlapping sessions
covering a broad range of topics in patient safety and health IT.
Speakers presented findings from their research and provided examples of
programs, policies, and technologies used to improve patient safety.
Each session placed emphasis on best practices in patient safety,
lessons learned, strategies, and the products and tools useful in
addressing potential challenges presented where patient safety
intersects with health IT. In the words of Carolyn M. Clancy, Director
of AHRQ, "*The evidence and positive results learned from our
investments in these areas will make the health care system safer*."

This document provides a synopsis of the major findings from the 2005
Patient Safety and Health IT Conference, as well as a broad overview of
the structure and content of conference activities. Chapter One begins
with a brief overview of Welcome and Opening Plenary remarks made by Dr.
Robert Wachter, then summarizes research findings from the patient
safety component and lists various tools and products developed and/or
used by grantees in addition to methodological and implementation
challenges faced, and future applications/next steps for grantees'
research.

Chapter Two covers the Patient Safety/Health IT crossover day, including
keynote speakers Carolyn Clancy, Director of AHRQ, Michael Leavitt,
Secretary of the Department of Health and Human Services, the Honorable
Nancy Johnson (R-Connecticut), Reed Tuckson, Senior Vice President of
Consumer Health and Medical Care Advancement for UnitedHealth Group, and
a panel of distinguished Congressional staffers and a media panel. And
finally, Chapter Three provides an overview of the health IT-themed days
and provides preliminary results emerging from AHRQ's Health IT grant
portfolio.

For greater detail, including power point presentations and video
recordings of select presentations go to:
<http://healthit.ahrq.gov/conf2005/materials.html>. In addition, you may
access the Annual Conference 2005 Calendar and click on any of the
hyperlinks to review Patient Safety and Health IT presentations, plenary
sessions, and keynote speakers.

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|   | | | #### Patient Safety (Monday, June 6 - Tuesday, June 7)  {# |  |  |
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|   | | |                                               [Track F: [\ |  |  |
|   | | |   Intersection o                                           |  |  |
|   | | | f Health IT and Patient Safety]{.underline}](http://health |  |  |
|   | | | it.ahrq.gov/conf2005/tracks/pstrack1.html)          Tools  |  |  |
|   | | | for Saving Patient Lives]{.underline}](http://healthit.ahr |  |  |
|   | | | q.gov/conf2005/tracks/pstrack2.html)              Patient  |  |  |
|   | | | Safety Across Settings and                                 |  |  |
|   | | |                                             Systems Issues |  |  |
|   | | |  and the Clinical Environment]{.underline}](http://healthi |  |  |
|   | | | t.ahrq.gov/conf2005/tracks/pstrack4.html)                E |  |  |
|   | | | ducation and Training for Safety]{.underline}](http://heal |  |  |
|   | | | thit.ahrq.gov/conf2005/tracks/pstrack5.html)               |  |  |
|   | | |            Using Reporting Systems Effectively]{.underline |  |  |
|   | | | }](http://healthit.ahrq.gov/conf2005/tracks/pstrack6.html) |  |  |
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|   | | |                                        Populations]{.under |  |  |
|   | | | line}](http://healthit.ahrq.gov/conf2005/tracks/pstrack3.h |  |  |
|   | | | tml)                                                       |  |  |
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|   | | |   [Robert M. Wachter,                                      |  |  |
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|   | | |   M.D.](http://healthit.ahr                                |  |  |
|   | | | q.gov/portal/server.pt/gateway/PTARGS_0_1371_41018_0_0_18/ |  |  |
|   | | | AHRQ Plenary 6.05.pdf)\                                    |  |  |
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|   | | |   Professor of Medicine and                                |  |  |
|   | | |  Chief of Medical Service,\                                |  |  |
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|   | | |   UCSF Medical Center                                      |  |  |
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|   | | |   [Avoiding Adver                                          |  |  |
|   | | | se Drug Events](http://healthit.ahrq.gov/conf2005/tracks/p |  |  |
|   | | | strack1.html#1. Avoiding Adverse Drug Events)      [Risk a |  |  |
|   | | | nd Recovery](http://healthit.ahrq.gov/conf2005/tracks/pstr |  |  |
|   | | | ack2.html#1. Risk and Recovery)                  [Hospital |  |  |
|   | | |  Care](http://healthit.ahrq.gov/conf2005/tracks/pstrack3.h |  |  |
|   | | | tml#1. Hospital Care)                      [Organizational |  |  |
|   | | |  Climate Matters: Direct and Indirect Effects on Patient   |  |  |
|   | | |                                                         [I |  |  |
|   | | | nforming Patients and Families about Adverse               |  |  |
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|   | | |           [Using Data Systems to Identify Potential Harm - |  |  |
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|   | | |                                         Safety](http://hea |  |  |
|   | | | lthit.ahrq.gov/conf2005/tracks/pstrack4.html#1. Organizati |  |  |
|   | | | onal Climate Matters: Direct and Indirect Effects)   Event |  |  |
|   | | | s](http://healthit.ahrq.gov/conf2005/tracks/pstrack5.html# |  |  |
|   | | | 1. Informing Patients and Families about Adverse Events)   |  |  |
|   | | |        I](http://healthit.ahrq.gov/conf2005/tracks/pstrack |  |  |
|   | | | 6.html#1. Using Data Systems to Identify Potential Harm-I) |  |  |
|   | | |                                                            |  |  |
|   | | |   [Using HIT to I                                          |  |  |
|   | | | mprove Care: Three Clinical                                |  |  |
|   | | |                                                    [Preven |  |  |
|   | | | ting Infections](http://healthit.ahrq.gov/conf2005/tracks/ |  |  |
|   | | | pstrack2.html#2. Preventing Infections)          [Older Pa |  |  |
|   | | | tient Care](http://healthit.ahrq.gov/conf2005/tracks/pstra |  |  |
|   | | | ck3.html#2. Older Patient Care)            [What Do Medica |  |  |
|   | | | l Errors Cost and Are System Changes Worth                 |  |  |
|   | | |                                                         [D |  |  |
|   | | | oes Team Training Make a Difference in Delivering Safe     |  |  |
|   | | |                                                            |  |  |
|   | | |           [Using Data Systems to Identify Potential Harm - |  |  |
|   | | |   Examples](http://hea                                     |  |  |
|   | | | lthit.ahrq.gov/conf2005/tracks/pstrack1.html#2. Using HIT  |  |  |
|   | | | to Improve Care)                                           |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                       It?](http://healthit |  |  |
|   | | | .ahrq.gov/conf2005/tracks/pstrack4.html#2. What do Medical |  |  |
|   | | |  Errors Cost and are System Changes Worth It)      Care?]( |  |  |
|   | | | http://healthit.ahrq.gov/conf2005/tracks/pstrack5.html#2.  |  |  |
|   | | | Does Team Training Make a Difference in Delivering Safe Ca |  |  |
|   | | | r)   II](http://healthit.ahrq.gov/conf2005/tracks/pstrack6 |  |  |
|   | | | .html#2. Using Data Systems to Identify Potential Harm-II) |  |  |
|   | | |                                                            |  |  |
|   | | |   [Hidden I                                                |  |  |
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|   | | |                                                          [ |  |  |
|   | | | Improving the Accuracy of Patient                          |  |  |
|   | | |                                                        [Am |  |  |
|   | | | bulatory Care](http://healthit.ahrq.gov/conf2005/tracks/ps |  |  |
|   | | | track3.html#3. Ambulatory Care)                  [Techniqu |  |  |
|   | | | es for Institutionalizing a Safety                         |  |  |
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|   | | |     [Health Care Education Tools - I](http://healthit.ahrq |  |  |
|   | | | .gov/conf2005/tracks/pstrack5.html#3. Health Care Educatio |  |  |
|   | | | n Tools-I)      [Using Reporting Systems Data for Action - |  |  |
|   | | |   I](http://he                                             |  |  |
|   | | | althit.ahrq.gov/conf2005/tracks/pstrack1.html#3. Hidden Is |  |  |
|   | | | sues in Implementing Technology - I)                  Iden |  |  |
|   | | | tification](http://healthit.ahrq.gov/conf2005/tracks/pstra |  |  |
|   | | | ck2.html#3. Improving the Accuracy of Patient ID)          |  |  |
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|   | | |                                               Culture](htt |  |  |
|   | | | p://healthit.ahrq.gov/conf2005/tracks/pstrack4.html#3. Tec |  |  |
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|   | | |     [Health Care Education Tools - II](http://healthit.ahr |  |  |
|   | | | q.gov/conf2005/tracks/pstrack5.html#4. Health Care Educati |  |  |
|   | | | on Tools-II)    [Using Reporting Systems Data for Action - |  |  |
|   | | |   II](http://hea                                           |  |  |
|   | | | lthit.ahrq.gov/conf2005/tracks/pstrack1.html#4. Hidden Iss |  |  |
|   | | | ues in Implementing Technology - II)                Events |  |  |
|   | | | ](http://healthit.ahrq.gov/conf2005/tracks/pstrack2.html#4 |  |  |
|   | | | . Preventing Adverse Drug Events)                 Care](ht |  |  |
|   | | | tp://healthit.ahrq.gov/conf2005/tracks/pstrack3.html#4. Mo |  |  |
|   | | | ving the Patient Across a System of Care)   Safety](http:/ |  |  |
|   | | | /healthit.ahrq.gov/conf2005/tracks/pstrack4.html#4. Assess |  |  |
|   | | | ing Your Health Care Environment for Safety)               |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |            II](http://healthit.ahrq.gov/conf2005/tracks/ps |  |  |
|   | | | track6.html#4. Using Reporting Systems Data for Action-II) |  |  |
|   | | |                                                            |  |  |
|   | | |   [Challenges of Impl                                      |  |  |
|   | | | ementing an Electronic Health                              |  |  |
|   | | |                                                [Improving  |  |  |
|   | | | the Safety of Cardiac                                      |  |  |
|   | | |                                              [Children\'s  |  |  |
|   | | | Care](http://healthit.ahrq.gov/conf2005/tracks/pstrack3.ht |  |  |
|   | | | ml#5. Children's Care)                 [Impact of Working  |  |  |
|   | | | Conditions on Patient                                      |  |  |
|   | | |                                                     [Are S |  |  |
|   | | | imulations Effective Training                              |  |  |
|   | | |                                                            |  |  |
|   | | |       [Using Reporting Systems Data to Engage Consumers in |  |  |
|   | | |   Record](http://healthit.ahrq.gov/c                       |  |  |
|   | | | onf2005/tracks/pstrack1.html#5. Challenges of Implementing |  |  |
|   | | |  an Electronic Health Record)   Care](http://healthit.ahrq |  |  |
|   | | | .gov/conf2005/tracks/pstrack2.html#5. Improving the Safety |  |  |
|   | | |  of Cardiac Care)                                          |  |  |
|   | | |                                                            |  |  |
|   | | |                         Safety](http://healthit.ahrq.gov/c |  |  |
|   | | | onf2005/tracks/pstrack4.html#5. Impact of Working Conditio |  |  |
|   | | | ns on Patient Safety)                Tools](http://healthi |  |  |
|   | | | t.ahrq.gov/conf2005/tracks/pstrack5.html#5. Are Simulation |  |  |
|   | | | s Effective Training Tools)                      Safety](h |  |  |
|   | | | ttp://healthit.ahrq.gov/conf2005/tracks/pstrack6.html#5. U |  |  |
|   | | | sing Reporting Systems Data to Engage Consumers in Safety) |  |  |
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|   | | | ############################# Plenary Sessions (Wednesday, |  |  |
|   | | |  June 8)  {#plenary-sessions-wednesday-june-8 .unnumbered} |  |  |
|   | | |                                                            |  |  |
|   | | |   -----------------------------------------------          |  |  |
|   | | | ---------------------------------------------------------- |  |  |
|   | | | ---------------------------------------------------------- |  |  |
|   | | | ---------------- ------------------ ---------------------- |  |  |
|   | | |   Event                                                    |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                    Description        Potential Speakers / |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                               Facilitators |  |  |
|   | | |                                                            |  |  |
|   | | |   [Welcome](http://healthit.ahrq.gov/conf2                 |  |  |
|   | | | 005/tracks/plenary.html#1. Welcome)                        |  |  |
|   | | |                                                            |  |  |
|   | | |                         Welcome by AHRQ    Carolyn Clancy, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                    Director           Director, Agency for |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        Healthcare Research |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                and Quality |  |  |
|   | | |                                                            |  |  |
|   | | |   [Keynote Address](http://healthit.ahrq.gov/              |  |  |
|   | | | conf2005/tracks/plenary.html#4. Keynote Address)           |  |  |
|   | | |                                                            |  |  |
|   | | |                      \-                 Honorable Nancy L. |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                             Johnson (R-CT) |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                           Chairman, Health |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                         Subcommittee House |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                      Committee on Ways and |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                      Means |  |  |
|   | | |                                                            |  |  |
|   | | |   [Opening Remarks](http://healthit.ahrq.g                 |  |  |
|   | | | ov/conf2005/tracks/plenary.html#3. Opening Remarks)        |  |  |
|   | | |                                                            |  |  |
|   | | |                         Opening Remarks by Carolyn Clancy, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                          AHRQ Director      Director, AHRQ |  |  |
|   | | |                                                            |  |  |
|   | | |   [Keynote 1](http://healthit.ahrq.gov/conf2005/           |  |  |
|   | | | tracks/plenary.html#2. Keynote Address by HHS Leadership)  |  |  |
|   | | |                                                            |  |  |
|   | | |                   Address By HHS     The Honorable Michael |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                   Leadership         O. Leavitt Secretary, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                              United States |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                       Department of Health |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        and Human Services\ |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                       *Introduced by Brent |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                       James Vice President |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                          Medical Research, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                              Intermountain |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                Healthcare* |  |  |
|   | | |                                                            |  |  |
|   | | |   [Keynote 2](http://healthit.ahrq.gov/conf2005            |  |  |
|   | | | /tracks/plenary.html#6. Innovations In Heath IT and Patien |  |  |
|   | | | t Safety Panel)                                            |  |  |
|   | | |                    Innovations in     *Moderators: Deborah |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                       Health IT and      Queenan and Scott |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                           Patient Safety     Young, AHRQ*\ |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                      Panel              Gail Bellamy, West |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                           Virginia Medical |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                          Institute/Quality |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                  Insights\ |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                             Kevin Johnson, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                      Vanderbilt University |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                             Bioinformatics |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                Department\ |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                       Hal Kaplan, Columbia |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                University\ |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                      Jan Root, Utah Health |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        Information Network |  |  |
|   | | |                                                            |  |  |
|   | | |   [Keynote 3](http://healthit.ahrq.gov/conf200             |  |  |
|   | | | 5/tracks/plenary.html#5. Congressional Staff Panel on Heal |  |  |
|   | | | th Policy)                                                 |  |  |
|   | | |                     Congressional      *Moderated By Scott |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                            Staff Panel On     Young, AHRQ* |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        Health Policy       |  |  |
|   | | |                                                            |  |  |
|   | | |   [Keynote 4](http://healthit.ahrq.gov/conf2005            |  |  |
|   | | | /tracks/plenary.html#7. Keynote: The Role of Health IT in  |  |  |
|   | | | Improving Health Care Quality)                             |  |  |
|   | | |                    The Role of Health Reed Tuckson, Senior |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                         IT in Improving    Vice President, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                      Health Care        UnitedHealth Group |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        Quality             |  |  |
|   | | |                                                            |  |  |
|   | | |   [Keynote 5](http://healthit.ahrq.gov/conf200             |  |  |
|   | | | 5/tracks/plenary.html#8. Behind the Scenes: How the News M |  |  |
|   | | | edia Covers New Developments in Patient Safety and Health  |  |  |
|   | | | IT)                 Behind the Scenes: *Moderator: Carolyn |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                      How the News Media Clancy, Agency for |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                     Covers New         Healthcare Research |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                           Developments In    and Quality*\ |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                            Patient Safety and David Brown, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                        Health IT          Washington Post\ |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                             John Hamilton, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                     National Public Radio\ |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                          Lauran Neergaard, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                          Associated Press\ |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                               Scott Weier, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                iHealthBeat |  |  |
|   | | |                                                            |  |  |
|   | | |   [Keynote                                                 |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                          Strategic          David Brailer, |  |  |
|   | | |   6](http://healthit.ahrq.gov/conf2005/tracks/p            |  |  |
|   | | | lenary.html#9. Strategic Framework for Improving Heath Car |  |  |
|   | | | e Through HIT: Update from the Office of the National Coor |  |  |
|   | | | dinator for HIT)   Framework for      National Coordinator |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                  Improving Health   for Health Information |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                              Care through HIT:  Technology |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        Update from the     |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        Office of the       |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        National            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        Coordinator for     |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        Health Information  |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                        Technology          |  |  |
|   | | |                                                            |  |  |
|   | | |   [Closing Remarks](http://healthit.ahrq.g                 |  |  |
|   | | | ov/conf2005/tracks/plenary.html#Summary and Closing Remark |  |  |
|   | | | s)                                                         |  |  |
|   | | |                         Summary and        Carolyn Clancy, |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |                          Closing Remarks    Director, AHRQ |  |  |
|   | | |   -----------------------------------------------          |  |  |
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|   | | | ########## Health IT (Thursday, June 9 - Friday, June 10)  |  |  |
|   | | |  {#health-it-thursday-june-9---friday-june-10 .unnumbered} |  |  |
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|   | | |                                                [Track B: [ |  |  |
|   | | | \                                                          |  |  |
|   | | |                                                         [T |  |  |
|   | | | rack C: [\                                                 |  |  |
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|   | | |    [Track D: [\                                            |  |  |
|   | | |                                                            |  |  |
|   | | |              [Track E: [\                                  |  |  |
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|   | | |                   [Track F: [\                             |  |  |
|   | | |                                                            |  |  |
|   | | |                                               [Track G: [\ |  |  |
|   | | |   Intersection of Health                                   |  |  |
|   | | | IT and Patient Safety]{.underline}](http://healthit.ahrq.g |  |  |
|   | | | ov/conf2005/tracks/hit_track1.html)                        |  |  |
|   | | |       Health Information Exchange]{.underline}](http://hea |  |  |
|   | | | lthit.ahrq.gov/conf2005/tracks/hit_track2.html)            |  |  |
|   | | |                Assessing Value and Evaluating Health IT]{. |  |  |
|   | | | underline}](http://healthit.ahrq.gov/conf2005/tracks/hit_t |  |  |
|   | | | rack3.html)         Public Trust in Health IT: Handling Pr |  |  |
|   | | | ivacy, Security and Related                                |  |  |
|   | | |                               Coordinating Care Using IT a |  |  |
|   | | | nd Telehealth]{.underline}](http://healthit.ahrq.gov/conf2 |  |  |
|   | | | 005/tracks/hit_track5.html)        Health IT Nuts & Bolts: |  |  |
|   | | |  Tackling the Technical Issues]{.underline}](http://health |  |  |
|   | | | it.ahrq.gov/conf2005/tracks/hit_track6.html)               |  |  |
|   | | |      Funding and Managing Health IT Projects]{.underline}] |  |  |
|   | | | (http://healthit.ahrq.gov/conf2005/tracks/hit_track7.html) |  |  |
|   | | |                                                            |  |  |
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|   | | |                                                            |  |  |
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|   | | |                                                            |  |  |
|   | | |                Issues]{.underline}](http://healthit.ahrq.g |  |  |
|   | | | ov/conf2005/tracks/hit_track4.html)                        |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
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|   | | |   Opening Plenary and Overview                             |  |  |
|   | | | :\                                                         |  |  |
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|   | | |                                                            |  |  |
|   | | |   Helen Burstin, AHRQ; Joy Kee                             |  |  |
|   | | | ler, National Resource Center for Health IT; Janet Marchib |  |  |
|   | | | roda, Ehi                                                  |  |  |
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|   | | |                                                            |  |  |
|   | | |   [Highlights of AHRQ\'s Patien                            |  |  |
|   | | | t Safety                                                   |  |  |
|   | | |                                                            |  |  |
|   | | | [HIE Planning: How to Get                                  |  |  |
|   | | |                                                            |  |  |
|   | | |          [Basic Study Design and Quantitative              |  |  |
|   | | |                                                            |  |  |
|   | | |               [HIPAA 101: Basic HIPAA Privacy and          |  |  |
|   | | |                                                            |  |  |
|   | | |                         [Health IT and Pediatrics](http:// |  |  |
|   | | | healthit.ahrq.gov/conf2005/tracks/hit_track5.html#1. Healt |  |  |
|   | | | h IT and Pediatrics)         [Organizational Redesign and  |  |  |
|   | | | Clinical                                                   |  |  |
|   | | |                                                          [ |  |  |
|   | | | HIT Project Management 101: Getting started and staying on |  |  |
|   | | |   Portfolio](http://healthit.ahrq.gov/conf2005/track       |  |  |
|   | | | s/hit_track1.html#1. Highlights of AHRQ's Patient Safety P |  |  |
|   | | | ortfolio)                            Started](http://healt |  |  |
|   | | | hit.ahrq.gov/conf2005/tracks/hit_track2.html#1. HIE Planni |  |  |
|   | | | ng: How to Get Started)                       Methods](htt |  |  |
|   | | | p://healthit.ahrq.gov/conf2005/tracks/hit_track3.html#1. B |  |  |
|   | | | asic Study Design and Quantitative Methods)        Securit |  |  |
|   | | | y](http://healthit.ahrq.gov/conf2005/tracks/hit_track4.htm |  |  |
|   | | | l#1. HIPAA 101: Basic HIPAA Privacy and Security)          |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |         Change](http://healthit.ahrq.gov/conf2005/tracks/h |  |  |
|   | | | it_track6.html#1. Organization Redesign and Clinical Chang |  |  |
|   | | | e)                                  track](http://healthit |  |  |
|   | | | .ahrq.gov/conf2005/tracks/hit_track7.html#1. Health IT Pro |  |  |
|   | | | ject Management 101, Getting Started and Staying on Track) |  |  |
|   | | |                                                            |  |  |
|   | | |   [Translating HIT into P                                  |  |  |
|   | | | atient Safety                                              |  |  |
|   | | |                                                            |  |  |
|   | | |       [HIE Organization and Governance Approaches and      |  |  |
|   | | |                                                            |  |  |
|   | | |                [Survey and Qualitative Methods for         |  |  |
|   | | |                                                            |  |  |
|   | | |                     [Privacy and Security: Practical       |  |  |
|   | | |                                                            |  |  |
|   | | |                               [Case Studies: Adoption of   |  |  |
|   | | |                                                            |  |  |
|   | | |                                    [Inter-institutional Da |  |  |
|   | | | ta Sharing, Standards and Legal                            |  |  |
|   | | |                                                            |  |  |
|   | | |      [Managing health IT in the real world: challenges and |  |  |
|   | | |   Practice](http://healthit.ahrq.gov/conf2005/tr           |  |  |
|   | | | acks/hit_track1.html#2. Translating HIT into Patient Safet |  |  |
|   | | | y Practice)                              Models](http://he |  |  |
|   | | | althit.ahrq.gov/conf2005/tracks/hit_track2.html#2. HIE Org |  |  |
|   | | | anization and Governance Approaches and Models)   Evaluati |  |  |
|   | | | on](http://healthit.ahrq.gov/conf2005/tracks/hit_track3.ht |  |  |
|   | | | ml#2. Survey and Qualitative Methods for Evaluation)   Con |  |  |
|   | | | siderations](http://healthit.ahrq.gov/conf2005/tracks/hit_ |  |  |
|   | | | track4.html#2. Privacy and Security: Practical Considerati |  |  |
|   | | | ons)   e-Prescribing](http://healthit.ahrq.gov/conf2005/tr |  |  |
|   | | | acks/hit_track5.html#2. Case Studies: Adoption of e-Prescr |  |  |
|   | | | ibing)      Implications](http://healthit.ahrq.gov/conf200 |  |  |
|   | | | 5/tracks/hit_track6.html#2. Inter-institutional Data Shari |  |  |
|   | | | ng, Standards and Legal Implications)   solutions](http:// |  |  |
|   | | | healthit.ahrq.gov/conf2005/tracks/hit_track7.html#2. Manag |  |  |
|   | | | ing Health IT in the Real World: Challenges and Solutions) |  |  |
|   | | |                                                            |  |  |
|   | | |   [Improving medication                                    |  |  |
|   | | | management and blood products                              |  |  |
|   | | |                                                            |  |  |
|   | | |        [Perspectives from the Front                        |  |  |
|   | | |                                                            |  |  |
|   | | |                 [Health IT Evaluation Case                 |  |  |
|   | | |                                                            |  |  |
|   | | |                      [Building a Culture of Confidentialit |  |  |
|   | | | y and                                                      |  |  |
|   | | |                                [Changing clinical practice |  |  |
|   | | |  for                                                       |  |  |
|   | | |                                     [Implementation and Tr |  |  |
|   | | | aining Strategies for                                      |  |  |
|   | | |                                                            |  |  |
|   | | |       [Funding Health IT, Government, Foundation and Payer |  |  |
|   | | |   administration](http://healthit.ahrq.gov/conf2005/       |  |  |
|   | | | tracks/hit_track1.html#3. Improving Medication Management  |  |  |
|   | | | and Blood Products Administration)   Lines](http://healthi |  |  |
|   | | | t.ahrq.gov/conf2005/tracks/hit_track2.html#3. Perspectives |  |  |
|   | | |  from the Front Lines)                        Studies](htt |  |  |
|   | | | p://healthit.ahrq.gov/conf2005/tracks/hit_track3.html#3. H |  |  |
|   | | | ealth IT Evaluation Case Studies)                  Securit |  |  |
|   | | | y](http://healthit.ahrq.gov/conf2005/tracks/hit_track4.htm |  |  |
|   | | | l#3. Building a Culture of Confidentiality and Security)   |  |  |
|   | | |    telehealth](http://healthit.ahrq.gov/conf2005/tracks/hi |  |  |
|   | | | t_track5.html#3. Changing Clinical Practice for Telehealth |  |  |
|   | | | )       Success](http://healthit.ahrq.gov/conf2005/tracks/ |  |  |
|   | | | hit_track6.html#3. Implementation and Training:Strategies  |  |  |
|   | | | for Success)                        Perspectives](http://h |  |  |
|   | | | ealthit.ahrq.gov/conf2005/tracks/hit_track7.html#3. Fundin |  |  |
|   | | | g Health IT, Government Foundation and Payer Perspectives) |  |  |
|   | | |                                                            |  |  |
|   | | |   [Overview of AHRQ\'s Nationa                             |  |  |
|   | | | l Resource Center for Health Information                   |  |  |
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|   | | |   Technology](http://healthit.                             |  |  |
|   | | | ahrq.gov/portal/server.pt/gateway/PTARGS_0_3048_40449_0_0_ |  |  |
|   | | | 18/wrapup.ppt)                                             |  |  |
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|   | | |   [Ask the Experts:                                        |  |  |
|   | | | Patient Safety and Health                                  |  |  |
|   | | |                                                            |  |  |
|   | | |            [Implementation and Beyond](http://healthit.ahr |  |  |
|   | | | q.gov/conf2005/tracks/hit_track2.html#4. Implementation an |  |  |
|   | | | d Beyond)           [Open Forum with HIT Evaluation        |  |  |
|   | | |                                                            |  |  |
|   | | |                          [Consumer Perspectives](http://he |  |  |
|   | | | althit.ahrq.gov/conf2005/tracks/hit_track4.html#4. Consume |  |  |
|   | | | r Perspectives)                    [Managing clinical hand |  |  |
|   | | | -offs across care                                          |  |  |
|   | | |                                         [Insights on New T |  |  |
|   | | | echnologies](http://healthit.ahrq.gov/conf2005/tracks/hit_ |  |  |
|   | | | track6.html#4. Insights on New Technologies)               |  |  |
|   | | |           [Mock Evaluation Panel, Health IT Implementation |  |  |
|   | | |   IT](http://healthit.ahrq.gov/conf2005/t                  |  |  |
|   | | | racks/hit_track1.html#4. Ask the Experts: Patient Safety a |  |  |
|   | | | nd Health IT)                                              |  |  |
|   | | |                                                            |  |  |
|   | | |                                                          E |  |  |
|   | | | xperts](http://healthit.ahrq.gov/conf2005/tracks/hit_track |  |  |
|   | | | 3.html#4. Open Forum With Health IT Evaluation Experts)    |  |  |
|   | | |                                                            |  |  |
|   | | |                                                            |  |  |
|   | | |               settings](http://healthit.ahrq.gov/conf2005/ |  |  |
|   | | | tracks/hit_track5.html#4. Managing Clinical Handoffs Acros |  |  |
|   | | | s Care Settings)                                           |  |  |
|   | | |                                                            |  |  |
|   | | |                                                Projects](h |  |  |
|   | | | ttp://healthit.ahrq.gov/conf2005/tracks/hit_track7.html#4. |  |  |
|   | | |  Mock Evaluation Panel, Health IT Implementation Projects) |  |  |
|   | | |                                                            |  |  |
|   | | |   [Closing Session:](http://he                             |  |  |
|   | | | althit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_3225_410 |  |  |
|   | | | 16_0_0_18/HIT Track Synthesis 6.10.05.PPT)\                |  |  |
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|   | | |   Summary of Key Take-Aways fr                             |  |  |
|   | | | om Track Chairs\                                           |  |  |
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|   | | |   Janet Marchibroda, eHI; Tom                              |  |  |
|   | | | Lloyd, Vanderbilt Center for Better Health\                |  |  |
|   | | |                                                            |  |  |
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|   | | |                                                            |  |  |
|   | | |   *Moderated by Carolyn Clancy                             |  |  |
|   | | | , Director, Agency for Healthcare Research and Quality*    |  |  |
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|   | | | [\^ top]()                                                 |  |  |
|   | | +------------------------------------------------------------+  |  |
|   | +-----------------------------------------------------------------+  |
+---+----------------------------------------------------------------------+

+---------------+------------------------------------------------------+
|               | # CHAPTER ONE:                                       |
|               |                                                      |
|               | # PATIENT SAFETY                                     |
+---------------+------------------------------------------------------+

## ^■^ Patient Safety in 2005: The End of the Beginning ^■^

On Monday June 6 Robert M. Wachter, Professor of Medicine and Chief of
Medical Service, University of California, San Francisco Medical Center,
welcomed meeting participants to AHRQ's Patient Safety and Health IT
Annual Conference and provided opening comments that set the overall
tone for the week. Dr. Wachter described recent trends in medical
safety, focusing his discussion on six key areas that have a direct
impact on patient safety, including *regulations, reporting systems,
teamwork training and simulation, clinical information technology, the
malpractice system, and workforce strategies*. He then reviewed the
degree to which the United States has progressed with respect to patient
safety and health IT by reviewing accomplishments and failures to date
in meeting the goals set for each of six key areas he identified.

According to Dr. Wachter, *regulations* have been the most significant
factor in driving patient safety, spearheaded by the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO). *Reporting systems*
have yielded only modest success, producing many reports but no clear
link to increases in patient safety. *Teamwork training and simulation*
reportedly show promise but remain undeveloped and require substantial
time and financial investments. *Clinical information technology* also
is costly but has made great strides in terms of gaining wider
acceptance among the patient safety community as a necessary component
to increasing efficiencies and improving patient safety. Although *the
malpractice system* reportedly has not yet revealed a clear link to
improving patient safety-- Dr. Wachter noted that the general issue of
accountability needs to be examined further. And lastly, *Workforce
strategies* have shown promise in improving patient safety, as evidenced
by the introduction of new care models (e.g., hospitalists,
intensivists, and coordinating generalists).

+---------------+------------------------------------------------------+
|               | # SESSIONS AND FINDINGS                              |
+---------------+------------------------------------------------------+

Conference sessions were divided into six tracks:

-   Intersection of Health IT and Patient Safety

-   Tools for Saving Patient Lives

-   Patient Safety Across Settings and Populations

-   Systems Issues and the Clinical Environment

-   Education and Training for Safety

-   Using Reporting Systems Effectively

Each track featured five discussion sessions the major findings of which
are included in this compendium.

+----------+-----------------------------------------------------------+
|          | # A. THE INTERSECTION OF HEALTH IT AND PATIENT SAFETY     |
+----------+-----------------------------------------------------------+

Discussion in Track A focused on various points of intersection between
patient safety and health IT. It consisted of five sessions: *Avoiding
Adverse Drug Events*, *Using Health Information Technology (HIT) to
Improve Care: Three Clinical Examples*, *Hidden Issues in Implementing
Technology 1 & 2*, and *Challenges of Implementing an Electronic Health
Record*.

High-level insights and findings from this track include:

-   Electronic Health Record (EHR) systems can be useful tools for
    avoiding adverse drug events, but they are rarely fully implemented
    with a drug warning function.

-   Computerized physician order entry systems (CPOEs) can greatly
    reduce medical errors in critical care settings if they are
    integrated with effective management and meaningful buy-in from
    clinical staff.

-   For some physicians, technology will reduce errors greatly; while
    for others, technology may increase errors if, for example, they are
    uncomfortable with the product.

-   When transitioning to an EHR it is vital to consider the effects due
    to interoperability to ensure quality assurance.

## ^■^ I. Avoiding Adverse Drug Events ^■^

Tejal Gandhi, of Brigham and Women's Hospital, discussed ways to avoid
adverse drug events using information technology---in particular,
computerized physician order entry systems (CPOEs). John Kralewski, of
the University of Minnesota, focused his discussion on some of the
causes of prescription drug errors within medical group practices.

### Findings

-   Root causes of drug errors often involve multiple prescriptions per
    patient, communication problems with providers, high volumes of
    patients, and an overall lack of adequate information.

-   The culture of the clinical practice influenced error rates whereas
    the incentive system did not.

-   Electronic Health Record (EHR) systems had little effect on error
    rates.

-   About half of the adverse drug events resulted from errors in the
    ordering stage.

-   Application of CPOE systems may reduce medication errors by as much
    as 80 percent.

-   Excessive alerts led to practitioners responding less often to
    patients.

### Tools

-   EHRs

-   CPOE systems (hardware, software, decision support), including
    guidelines, allergy indications, and dose warnings

### Methodological and implementation challenges

-   Many EHRs do not activate a drug warning function.

-   EHRs often are unable to communicate to other EHRs.

-   EHRs often have separate laboratory files that are not integrated
    into a drug warning system.

-   CPOEs need to be employed (e.g., in tiered approaches) to reduce
    excessive alerts.

### Future applications, next steps

-   Conduct studies of the impact of CPOEs on adverse drug events and
    determine cost/benefit values.

-   Determine how best to alert practitioners of errors and encourage
    them to respond.

-   Study potential outpatient order entry systems.

## ^■^ II. Using Health Information Technology (HIT) To Improve Care: Three Clinical Examples ^■^

Andrew Steele, of Denver Health, described a study that used CPOE
systems in a critical care setting. David Magid, of Kaiser Permanente's
Clinical Research Unit, focused his discussion on efforts to improve
safety in prescribing medications for kidney patients. Jonathan Neufeld,
of the University of California, described a study of risks and benefits
in a Health IT program to increase the safety of the use of the
anticoagulant warfarin, misuse of which accounts for almost 10 percent
of all adverse drug events.

### Findings

-   Application of CPOE in a critical care setting reduced errors by
    more than 80 percent.

-   CPOE in the critical care setting increased efficiency by
    significantly reducing the time involved in collecting laboratory
    data and radiology exams.

-   A controlled study of the use of a pharmacy-based electronic warning
    system for prescribing medications to kidney disease patients
    resulted in a significant reduction in errors.

### Tools

-   CPOE system hardware, software, and decision support

### Methodological and implementation challenges

-   Success of CPOE in critical care settings requires commitment of the
    executive staff and physician champions.

-   Implementation of CPOE in critical care settings requires changes in
    workflow and policy.

-   The institution must use resources to customize the application
    provided by the vendor.

-   The use of a CPOE system requires training for universal computer
    literacy and flexibility and requires 24/7 technical support

-   Provider resistance to the system may occur (e.g., the electronic
    pharmacy warning system).

-   CPOE systems must be integrated into other systems.

-   Data for the CPOE system must be made available.

-   The definition of "usual care" varies across sites with respect to
    the use of warfarin.

## ^■^ III. Hidden Issues in Implementing Technology--I ^■^

Ben-Tzion Karsh of the University of Wisconsin-Madison, provided a
summary of implementation science, based on experience with a program
titled Systems Engineering Initiative for Patient Safety (SEIPS).
Kimberly Galt of Creighton University Medical Center, reported results
from a randomized study of the effects of personal digital assistance
devices (PDAs) on medication-prescribing errors for primary care
physicians in office-based practices. Ross Koppel of the University of
Pennsylvania, reported results from a study of medical errors associated
with the use of a CPOE system, focusing on stressors such as changing
shifts and sleeplessness.

### Findings

-   Issues such as the environment, error management, workplace
    conditions, perceptions about safety, and safety education often go
    beyond the reach of technology

-   Use of PDA devices significantly reduced errors associated with
    legibility, prescription omissions, and use of
    abbreviations/symbols.

-   PDA use may not improve the problem of "vagueness."

-   A CPOE system may lead to errors related to fragmentation of data
    and poor integration of information systems.

-   A CPOE system may lead to errors related to flaws in the
    human-machine interface (e.g., when machine rules do not correspond
    with organizational flow).

### Tools

-   Technology-implementation models based on theory

-   PDA (a hand-held data entry device)

-   CPOE system (hardware, software, decision support)

### Methodological and implementation challenges

-   New processes can create new errors.

-   Some physicians are reluctant to adopt new systems (e.g., PDAs).

-   Perceived time required to print a prescription from the PDA and a
    perception that using the PDA is cumbersome.

-   Some offices may not be capable of handling new systems.

### Future applications, next steps

-   Determine whether PDAs can be integrated into office-based
    practices.

-   Consider all organizational factors surrounding the use of a CPOE
    system.

-   For CPOE systems, plan for continuous revision and quality control.

## ^■^ IV. Hidden Issues in Implementing Technology--II ^■^

Richard Cook of the University of Chicago, described the dynamics of
patient safety as systems undergo technological change, emphasizing the
reliance of successful IT on the involvement of end users. Matthew
Weinger of Vanderbilt University, outlined the barriers to successful
implementation of Health IT.

### Findings

-   Many hospitals view the adoption of IT as an implementation problem
    rather than an exploratory process.

-   Vendors and hospitals often underestimate the complexity of IT
    systems.

-   Health IT has yet to realize goals such as delivering
    evidence-based, effective, on-time health care; documentation that
    is accurate, accessible, and secure; seamless interconnectivity and
    communication; and real-time support.

-   Home-grown Health IT systems best meet local needs.

### Tools

-   Home-grown Health IT systems

### Methodological and implementation challenges

-   Health IT systems come up short when insufficient resources are
    applied.

-   Technology is not yet mature and standards or interconnectivity are
    lacking.

-   Defective health care infrastructures.

-   Workflow inefficiencies and increased clinician workloads.

-   The greatest need for and benefits of technology are at the margins
    of care, where technology may be less reliable and difficult to
    implement.

### Future applications, next steps

-   Partnerships with Health IT developers.

-   Better understanding of user environments and end-user needs.

-   Including end users in designing Health IT.

## ^■^ V. Challenges of Implementing an Electronic Health Record ^■^

Eric Marks of the U.S. Department of Defense Center for Education and
Research in Patient Safety, presented results from a program in which
the DoD and the Veterans Administration developed an electronic
interface to share medical data. William Munier of AHRQ, described the
benefits and challenges of implementing an electronic health records
(EHR) system.

### Findings

-   Integrating the DoD and VA systems required: clear lines of
    authority for decision-making; standardized clinical data sets; and
    an architecture for the electronic interface.

-   Clearly elucidating goals and tasks with respect to implementing and
    testing software were vital to integrating the DoD and VA systems.

-   The implementation of an EHR by Main Street Pediatrics resulted in
    more accurate billing, improved efficiency, labor savings, reduced
    office-supply costs, a slight reduction in malpractice rates, and a
    large increase in net income over a 4-year period.

-   The EHR system needs a committed champion-user and vendor.

### Tools

-   An electronic health records interface (design, systems, software)

### Methodological and implementation challenges

-   Integrating two systems required significant project management to
    ensure accountability.

-   Abrupt transition to an EHR may temporarily reduce productivity and
    income.

-   Costs and logistical support needed to create interoperable EHR
    systems are significant.

-   Despite multiple EHR systems and vendors, there is a lack of
    incentives to standardize.

-   Privacy, security, and infrastructure concerns at the government
    level.

-   Privacy concerns for patients.

-   Patients will face different EHR systems when visiting multiple
    providers.

### Future applications, next steps

-   Standardize EHR practices.

-   Increase interoperability of EHR systems.

-   Develop better systems of quality assurance.

+----------+-----------------------------------------------------------+
|          | # B. TOOLS FOR SAVING PATIENT LIVES                       |
+----------+-----------------------------------------------------------+

Track B, Tools for Saving Patient Lives, provided an opportunity for
Patient Safety grantees to share their success stories. Track B
consisted of five sections: *Risk and Recovery, Preventing Infections,
Improving the Accuracy of Patient Identification, Preventing Adverse
Drug Events* and *Improving the Safety of Cardiac Care*.

High-level insights and findings from this track include:

-   Medical Emergency Teams (METs) are effective at reducing mortality,
    morbidity, and length of hospital stay.

-   Programs to reduce medical errors may not always seem cost effective
    but can greatly reduce long-term costs.

-   Improved identification technology, including wristbands and
    fingerprinting, may reduce medical errors greatly.

-   Effective triage in cardiac cases can lead to greatly reduced costs
    and errors.

## ^■^ I. Risk and Recovery ^■^

Michael Westley of Virginia Mason Medical Center in Seattle, described
the activities of a Medical Emergency Team (MET) program, in which a
team of emergency personnel respond rapidly to special cases based on an
established list of criteria. Marlene Goldman, of Beth Israel Deaconess
Medical Center, examined error and risk within a labor-and-delivery
environment.

### Findings

-   The MET approach significantly reduced mortality from cardiac
    arrest, postoperative morbidity and mortality, and the average
    length of stay in the hospital following cardiac arrest.

-   It is feasible to evaluate system-related factors and how they
    affect the delivery of care within the labor-and-delivery
    environment.

-   Increasingly, physicians are recognizing the critical
    interdependence between labor and delivery inputs; and interventions
    may be developed to mitigate the risks, while still protecting
    existing strengths.

-   Historically, physicians have focused on patient and procedural
    factors in the labor and delivery setting. Now they also focus on
    system and provider factors.

-   In a study of labor-and-delivery errors, 26 of 29 errors involved
    failures to diagnose and 23 involved procedural errors.

-   Labor-and-delivery is a complex system with factors interacting in
    myriad ways to affect risk and safety.

### Tools

-   Instructions for using the MET process, including emergency criteria
    and a calling code

-   Fault-tree analysis tools to assess correctable and non-correctable
    errors, facilitating physicians in tracking interrelated factors
    heretofore not detected early on

-   Plasma Rennin Activity (PRA) approach to model risk and recovery

### Methodological and implementation challenges

-   A successful MET program requires available, accessible, and capable
    health care workers.

### FuTUre applications, next steps

-   Develop and test interventions for error reduction.

-   Observations and fault-tree analysis may suggest areas for future
    research.

## ^■^ II. Preventing Infections ^■^

Denise Kirley of St. Joseph's Hospital, described efforts to reduce
urinary tract infections using a new bacteria-resistant urinary
catheter. Robert Panzer of the University of Rochester, described the
results of a program to reduce infections by providing specialized
"bundled care" to intubated patients in a critical care facility.
Richard Shannon of West Penn Allegheny Health System, discussed results
from an effort to reduce or eliminate central line-associated
bloodstream infections (CLABs) in intensive care units.

### Findings

-   The St. Joseph's study found that bacteria-resistant catheters could
    reduce the occurrence of catheter-caused urinary tract infections by
    about 50 percent.

-   Use of bacteria-resistant catheters reduced secondary bacteremia by
    about 86 percent.

-   Bacteria-resistant catheters are easy to implement and similar to
    standard devices (i.e., not a steep learning curve).

-   A "bundle" of care provided to intubated patients in an intensive
    care unit resulted in 525 consecutive days without a
    ventilator-associated pneumonia case.

-   The West Penn Allegheny approach to analysis, countermeasures, and
    reassessment reduced the number of CLABs in intensive care from 49
    to 6 per year (before and after the program).

-   The human and financial costs of CLABs are daunting and ordinarily
    do not include the costs of physicians and skilled nurses.

### Tools

-   Silver-alloy, hydrogel-coated standard catheter (latex or silicone)

-   A "bundle" of care including standard procedures, daily goals, and
    checklists

-   A program of root-cause analysis, countermeasures, and reassessment

### Methodological and implementation challenges

-   Cost of the device (bacteria-resistant catheters)

-   Training and developing a culture of change

### Future applications, next steps

-   Spread the bundle strategy to other intensive care units, the
    emergency department, and other departments.

## ^■^ III. Improving the Accuracy of Patient Identification ^■^

Kristy Walker of the University of Iowa, presented results from a pilot
study that employed wireless mobile devices, bar codes, and an online
database to reduce errors associated with blood product transfusions.
Karen Simpson of South Georgia Medical Center, described a new system of
standardized patient armbands and barcode technology that resulted in a
large reduction in errors associated with glucose measurements and other
areas.

### Findings

-   The Iowa pilot study showed fewer errors, and they were caught
    earlier in the process.

-   Errors are caused by internal system factors (e.g., coding errors,
    patient misidentification, etc.) and external factors (e.g.,
    culture, reluctance to use the system).

-   Barcode systems are less costly than radio frequency identification
    systems.

-   Root-cause analysis and group discussions are appropriate methods
    for addressing the problem of workarounds.

### Tools

-   Armband scanning systems that include barcode labels for armbands,
    blood samples, and paper forms

### Methodological and implementation challenges

-   Some wristbands may be inaccessible.

-   Logistical difficulties, such as same-day surgeries, complicate the
    use of the coding/scanning system.

-   Health care workers may be unfamiliar with the system's symbols.

-   Health care workers may "work-around" the system.

-   It is crucial that vendors supply the correct tools for the system.

### Future applications, next steps

-   Work with anesthesiologists to make the systems operate more
    smoothly.

-   Work with quality assurance personnel to increase use of the
    systems.

-   Employ new software to produce enhanced reports.

-   Consider using methods such as algorithmic logic to reduce errors
    during the patient registration process.

-   Consider the use of fingerprinting technology.

-   Extend the use of these technologies to areas such as room cleaning.

## ^■^ IV. Preventing Adverse Drug Events ^■^

Brett Carter of Tanner Health System, reported results from an effort to
re-engineer an acute-care pharmacy department to reduce medication
errors. Brian Strom at the University of Pennsylvania Medical Center,
described a program for reducing medication errors specifically intended
to limit unnecessary hospitalization of the elderly. Kathy McWhorter of
West Georgia Health System, presented findings on the effects of an
interdisciplinary team approach to reducing medication errors, using
nursing, pharmacy, long-term care, and executive staff.

### Findings

-   In the Tanner Program, nurses indicated that the program had a
    positive impact on care (e.g., 86% reported that medication
    administration was safer).

-   Pharmacy staff noted an increased ability to make a positive impact
    on patient care (e.g., 94 percent reported that medication delivery
    was safer, based on survey).

-   The use of electronic pill-cap monitors can measure compliance to
    pharmacological regimens, and the use of an MBMD
    inventory/questionnaire can measure general medical compliance.

-   High-risk medications (e.g., warfarin, phenytoin, and disoxin)
    increase medication errors and can lead to acute renal failure.

-   A non-punitive strategy involving monthly reviews of error
    summaries, a quarterly newsletter, and an incentive/award for
    identifying level-0 (near miss) errors may achieve positive results.

### Tools

-   Model for training and redeploying staff (e.g., pharmacists on
    nursing units)

-   Pyxis computerized medication distribution system

-   Daily chart review and pharmacotherapy assessment tool

-   Error tracking and assessment tool

-   Electronic pill-cap monitors that indicate when the container has
    been opened

-   Questionnaires for reducing medication errors and hospitalization of
    the elderly

-   Newsletter about errors and error reduction

-   An awards program for identifying near-misses

### Methodological and implementation challenges

-   Methodological concerns of nurses and pharmacy staff.

-   Limitations on information gleaned from pill-cap monitors and
    questionnaires.

## ^■^ V. Improving the Safety of Cardiac Care ^■^

Harry Selker of Tufts-New England Medical Center, presented results from
the use of predictive decision support tools in emergency-department
cardiac care. Therese White, Hamilton Health Care System, described the
use of best-practice prompt tools to improve safety and care in Hamilton
Medical Center's cardiovascular services.

### Findings

-   The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument
    (ACI-TIPI) used as part of the electrocardiograph and applied in an
    emergency room setting detects the probability that patients with
    symptoms of acute coronary syndromes will suffer acute myocardial
    infarction.

-   Use of the ACI-TIPI in emergency departments improves emergency room
    triage and frees up critical care unit and telemetry ward beds for
    acute coronary syndrome (ACS) patients.

-   Improved emergency room triaging using the ACI-TIPI saves \$120 per
    patient with chest pain-related symptoms and \$200 per patient in
    reduced medical malpractice costs.

-   Use of a thrombolytic predictive instrument increases the use and
    timeliness of reperfusion in the fraction of patients that otherwise
    would go undetected.

-   Retrospective use of ECG-based time-insensitive predictive
    instruments (TIPIs) facilitates physician performance monitoring and
    assessment and improves diagnosis (ACI-TIPI) and reperfusion.

-   Hamilton Medical Center achieved maximum JCAHO accreditation due in
    part to the use of prompt tools for best practices in cardiovascular
    services.

### Tools

-   Cardiac TIPI used with an electrocardiograph.

-   Prompt tools and training (acute myocardial infarction, congestive
    heart failure).

-   Discharge instructions for nursing associates to ensure patients are
    sent home with appropriate educational materials and tools.

-   Best practice compliance forms for nursing associates to identify
    acute myocardial infarction, congestive heart failure, and other
    cardiac-related defects.

### Methodological and implementation challenges

-   Ensuring that instruments for physician use are convenient and
    easy-to-use.

### Future applications, next steps

-   Consider other issues that compromise care as predictive instruments
    are applied.

-   Use preprinted discharge orders for each cardiovascular pathway.

-   Restructure the case management department to acquire more real-time
    data.

-   Use prompts in shift assessments.

+----------+-----------------------------------------------------------+
|          | # C. PATIENT SAFETY ACROSS SETTINGS AND POPULATIONS       |
+----------+-----------------------------------------------------------+

^Track\ C,\ Patient\ Safety\ Across\ Settings\ and\ Populations,\ consisted\ of\ five\ sections:\ *Hospital\ Care*,\ *Older\ Patient\ Care*,\ *Ambulatory\ Care*,\ *Moving\ the\ Patient\ Across\ a\ System\ of\ Care*,\ and\ *Children's\ Care*.\ Discussion\ in\ Track\ C\ focused\ on\ factors\ that\ strongly\ suggest\ that\ patient\ safety\ improvement\ be\ tailored\ to\ the\ environment.^

High-level insights and findings from this track include:

-   Local and state legislatures can prove to be a strong ally in
    improving Patient Safety infrastructure and capacity.

-   It is important to include near misses in order to prevent future
    errors.

-   Transitional times are a key moment when errors occur among older
    patients.

-   Technology can greatly reduce administrative errors.

-   Process mapping is an extremely useful tool for understanding when
    and how errors occur and provides insight into error prevention.

-   Dosing errors are very common in pediatric patients, and many could
    be avoided with improvements to weight and dosing data.

## 

## ^■^ I. Hospital Care ^■^

Brian Jack of the Boston Medical Center, focused his discussion on
discharge factors related to hospital readmission and a proposal for
re-engineering the discharge process. Jay Wolfson of the University of
South Florida, Tampa, discussed safety in the transitional phase and
home care. Shawna Perry at the University of Florida Health Science
Center, reported results from a study of Emergency Department signovers.

### Findings

-   Ideas for re-engineering the discharge process include written roles
    and responsibilities, patient education, information flow, discharge
    resume, and a written plan.

-   Maintaining proper staff at all times, providing patients with
    readable information, and benchmarking may lead to safety
    improvements in the discharge process.

-   Successful strategies for increasing safety in transitional care
    include effective communication pathways, education and training,
    assessment of insurance/reimbursement issues, and IT improvements.

-   The Florida legislature created the Florida Patient Safety
    Corporation to increase the capacity to improve patient safety,
    linking it to malpractice reform.

-   A study of handovers in an emergency department environment revealed
    a number of factors that influence performance, including the
    environment (hospital and ED), credibility, competency, perceptions,
    and roles.

-   Effective ED handovers are hampered by nurses and doctors
    transitioning separately; an absence of formal tools; shift changes,
    and other interruptions.

### Tools

-   Written discharge plans

-   Audiotaped shift changes

-   A near-miss voluntary reporting system (in the pilot phase in
    Florida)

## ^■^ II. Older Patient Care ^■^

Judy Sangl, from the Agency for Healthcare Research and Quality,
presented for Eric Coleman of the University of Colorado Health Sciences
Center, and discussed the issue of safety as it relates to transitioning
older patients across settings and populations. Terry Field, from the
University of Massachusetts Medical School, reviewed data issues
regarding adverse drug events (ADEs) among older adults in the hospital,
ambulatory, home care, and long-term care settings, and offered possible
modes of intervention to reduce ADEs.

### Findings

-   Core components associated with transitioning older patients
    effectively include: screening for high-risk patients; identifying
    patients'/caregivers' goals and preferences; excellent communication
    among and between providers across settings; patient/caregiver
    education on prevention and early identification of health problems;
    and advanced practice nurses (APNs) to navigate though the system
    and promote continuity.

-   Nurses found the electronic CMS 485 form -- used for transitioning
    patients to home care, featuring built-in evidence-based order sets
    that physicians can complete in three minutes -- easy to read and
    comprehensive.

-   National efforts to enhance transition safety include a call by the
    National Quality Forum for performance measures, JCAHO patient
    safety goals, and (soon) an Institute for Healthcare Improvement
    initiative on hospital discharge.

-   Focusing on the prescribing and administration phases and using
    computerized order checking assists in reducing ADEs.

-   Medication administration errors in the hospital setting are often
    related to unusual doses, administration frequencies, and
    variability across units.

-   Challenges to improving the quality of transitions for older
    patients are evident at multiple levels -- patient, practitioner,
    health care institutions, and IT.

### Tools

-   Electronic CMS 485 form

-   CPOE, bar coding, automated dispensing, clinical decision support
    systems

-   Medication Discrepancy Tool
    ([www.caretransitions.org](../www.caretransitions.org))

-   Care Transitions Measure
    ([www.caretransitions.org](../www.caretransitions.org))

-   Protocol Manual, *An Interdisciplinary Team Approach to Improving
    Transitions across Sites of Geriatric Care*
    ([www.caretransitions.org](../www.caretransitions.org))

-   "No Tears" Tool (Lewis, BMJ, Aug, 21, 2004), a tool for geriatric
    medication review

### Methodological and implementation challenges

-   Many transitions are unplanned and thus unavoidable.

-   Transitional care often involves physicians that do not have an
    ongoing relationship with the patient.

-   There are many levels of transition for example within, between, and
    across health care settings.

-   Transition involves multiple components (e.g., patient,
    practitioner, institution, and technology) all of which need to
    coordinate effectively.

### Future applications, next steps

-   Allow for a more active role for patients.

-   Establish "sending teams" and "receiving teams."

-   Extend best practices developed by individual institutions.

-   Employ information technology, such as CPOE and decision support
    systems.

-   Study the impact of low-tech interventions on ADEs among older
    adults, such as greater involvement of pharmacists, labeling drugs
    with geriatric specific information, and communicating within and
    across health care settings.

-   Develop a universal care transfer form.

-   The health care system should revise contract language to promote
    safe and effective transfers.

-   Conduct additional research on ADEs within the home health care
    setting.

## ^■^ III. Ambulatory Care ^■^

C. Andrew Brown at the University of Mississippi Medical Center,
described a program to improve medication management in the rural
ambulatory health care setting. Nancy Elder of the University of
Cincinnati, examined safety issues within outpatient primary care
offices, focusing on the testing process.

### Findings

-   The use of a computer-based error-reporting system affected an
    increase in the reporting of medical errors and a decrease in the
    numbers of adverse events: intercepted errors rose to 83 percent of
    all errors, and the time to process an error was reduced from about
    4 weeks to 4 hours.

-   Most errors in family physician offices are systems and
    administrative-related errors.

-   The process of patient testing involves multiple steps (ordering,
    tracking, responding, notifying, and following up) and multiple
    individuals -- both of which contribute an increased likelihood of
    error.

-   Strategies for reducing errors in the testing process should target
    cognitive skills, technology, system design and implementation, the
    patient-safety culture, communication skills, and patient
    empowerment and involvement.

-   Specific strategies for reducing errors include standardization of
    ordering, confirmation of procedures, tracking systems, planned
    redundancy, standardized electronic responses, documentation,
    patient notification, and follow up.

### Tools

-   A computer-based error-reporting system that was broadcast to
    providers across the state, targeting small rural hospitals.

### Methodological and implementation challenges

-   Difficulty involved in changing preexisting culture

-   The initial costs of electronic systems

### Future applications, next steps

-   Study and evaluate the effects of interventions.

## ^■^ IV. Moving the Patient across a System of Care ^■^

John Grout of Berry College, demonstrated the benefits of using process
mapping to analyze and reduce the occurrence of medical errors. Sharon
Martin at the University of Texas M. D. Anderson Cancer Center,
discussed a system view of care, focusing on the analysis of room
utilization as it relates to improving care.

### Findings

-   Process mapping focuses on the points in a process where errors
    occur; enhanced mapping indicates where handoffs and collaborations
    occur.

-   To promote patients' involvement in a way that avoids errors, system
    planners must reduce the use of jargon and make the process more
    transparent.

-   The system view holds that all parts interact and are
    interdependent; that it is nonlinear, multidimensional and dynamic;
    patients are components of the system; and variation may inhibit
    improvement.

-   Options should be presented as "risk-versus" consequences.

-   Many solutions do not require expensive resources.

-   Improvements across a system require a systematic, comprehensive,
    interdisciplinary approach.

### Tools

-   Mistake-proof codes and locks (e.g., on blood samples) can prevent
    errors

-   Analytical methods: theory of constraints, process mapping, lean
    thinking, and system dynamics modeling

### Methodological and implementation challenges

-   Process improvement involves a paradox: avoiding process improvement
    and spending time on "core work" leads to short-term improved
    performance, yet the process deteriorates over time -- creating
    greater need for process improvement and greater need to accomplish
    core work.

## ^■^ V. Children's Care ^■^

Heather McPhillips of the University of Washington Children's Hospital
and Regional Medical Center, presented results from a study of
outpatient medication dosing errors in children. Marlene Miller of Johns
Hopkins Children's Center, presented an overview of issues related to
medication errors in pediatric medicine. Paul Sharek, of Stanford
University School of Medicine, reported results from a program to reduce
inpatient adverse drug events.

### Findings

-   One study focusing on the effects of 22 children's medications found
    a high potential for analgesic overdosing and a high potential for
    underdosing antibiotics and anti-epileptic medications (University
    of Washington).

-   Dosing errors are common in ambulatory pediatrics.

-   Younger children are at higher risks for dosing errors, especially
    children that have not been seen in a clinic, are taking multiple
    medications and those taking medications on an as-needed basis.

-   Safety walk-rounds in which leaders visibly show their commitment to
    change, combined with open communication, can produce a culture
    amenable to improving safety.

-   Requiring that a patient's weight be noted on pediatric
    prescriptions would allow pharmacists to check the appropriateness
    of each dose.

-   A comprehensive safety program at one hospital found that processes
    that minimize steps and save time are more likely to succeed.

-   In the medication management process, it is best to automate as many
    steps as possible.

-   Additional actions to reduce adverse drug events may include
    instituting a safety officer and safety action teams; using
    electronic incident reporting systems; increasing the transparency
    of safety data; using an intranet for medication education, and
    using preprinted orders (standardized, etc.).

### Tools

-   A category on prescription forms for a pediatric patient's weight

-   Valid and reproducible outcomes measures

### Methodological and implementation challenges

-   Dosing for children is complex due to factors such as weight/dose
    calculations and a lack of standards).

### Future applications, next steps

-   Electronic prescribing with pediatric decision support.

-   Standardization of medication doses for children.

+----------+-----------------------------------------------------------+
|          | # D. SYSTEMS ISSUES AND THE CLINICAL ENVIRONMENT          |
+----------+-----------------------------------------------------------+

Track D, Systems Issues and the Clinical Environment, focused discussion
on system-wide issues that may have an impact on the implementation and
success of patient safety programs. This track consisted of five
sessions: *Organizational Climate Matters: Direct and Indirect Effects
on Patient Safety*, *What do Medical Errors Cost and Are System Changes
Worth It?*, *Techniques for Institutionalizing a Safety Culture*,
*Assessing Your Health Care Environment for Safety*, and *Impact of
Working Conditions on Patient Safety*.

High-level insights from this track include the following:

-   Organizational climates and culture are directly and indirectly
    associated with a wide spectrum of patient outcomes.

-   It is cost effective to implement CPOEs (i.e., reducing errors
    outpaces the costs hospitals incur from ADEs).

-   Safety culture may be very different between management and
    frontline staff, and therefore it should be assessed at both levels
    prior to the start of an ADE intervention.

-   Surveying staff on the culture of safety can help make positive
    changes. One useful instrument is the Hospital Survey on Patient
    Safety Culture (HSOPSC).

-   Harsh working conditions and long work hours can markedly increase
    the incidence of medical errors.

## ^■^ I. Organizational Climate Matters: Direct and Indirect Effects on Patient Safety ^■^

Michael Harrison, Agency for Healthcare Research and Quality, presented
results of an analysis of safety aspects across multiple centers that
employed an empirical climate model. Nicholas Warren, University of
Connecticut Health Center, described the organizational climate in the
VHA and its association with employee health and patient safety.
Patricia Stone of Columbia University, presented the results of a study
examining the effect of organizational culture on ICU nurses' intentions
to leave the workplace, and other working conditions variables on
patient safety outcomes in the ICU. Robert Rosati, Visiting Nurse
Service of New York, presented results from a survey assessing the
impact of organizational team characteristics on the incidence of
adverse patient events in the home health care setting.

### Findings

-   Harrison's climate model found similar patterns of relationships
    across studies.

-   Findings from the model suggested that it is easier to predict an
    employee's (i.e., health care worker's) satisfaction than to predict
    an employee's intention to leave.

-   In Warren's study, the organizational climate domains were directly
    associated with a wide variety of employee outcomes.

-   Organizational climates and culture are directly and indirectly
    associated with a wide spectrum of patient outcomes.

-   Leadership values and patient-centeredness were important aspects of
    quality emphasis.

-   Factors related to a nurse's intention to leave a critical care
    workplace include participatory governance, supervisor relations,
    and additional nurse training.

-   Patients' health care risks are positively related to ICU nurse
    overtime.

-   Patients' health care risks of acquiring infections are not related
    to ICU nurse intention to leave or ICU staffing ratios.

-   ICU nurse overtime is positively related to patients' risk of
    health-care acquired infections.

-   Adverse event rates in the home health care setting are lower for
    teams experiencing higher volume and concentration of visits, fewer
    weekend admissions, more experienced clinicians, greater perceived
    equity and teamwork, lower perceived supervisor safety culture, and
    less workload manageability.

-   There are higher rates of reported adverse events among teams in the
    home health care setting where safety culture is emphasized, perhaps
    due to heightened awareness and urgency placed on reporting.

-   Interventions designed to improve safety and quality of patient care
    should address organizational climate and employee working
    conditions.

-   Work design, safety culture, teamwork, and workforce characteristics
    affect team-attributable adverse event rates in the home health care
    setting.

### Tools

-   Empirical climate model

-   Surveys

### Methodological and implementation challenges

-   Challenges related to using secondary data analyses.

-   The inability to pool data in the model analysis and link it to
    health outcomes (Harrison).

-   Collecting reliable and valid data and achieving appropriate
    response rates in cross-sectional surveys.

### Future applications, next steps

-   The association between better patient safety outcomes among teams
    in the home health care setting and a less manageable workload
    raises questions about possible "burnout" among high-performing
    teams and complacency among poorer performing teams and points to a
    need for additional research.

-   Develop better models of organizational culture.

-   Design and evaluate interventions to improve teamwork to reduce
    adverse events.

-   Develop a diagnostic tool to predict the likelihood of future
    adverse events.

-   Develop models with components of organizational culture, not just a
    composite measure.

## ^■^ II. What Do Medical Errors Cost and Are System Changes Worth It? ^■^

Steven Culler of the Rollins School of Public Health, Emory University,
provided findings from a program implemented in an acute-care hospital
setting in Georgia, and examined the costs of employing a computerized
physician order entry (CPOE) system. In general, smaller hospitals
tended to lack plans to introduce CPOE systems. Chunliu Zhan, of the
Agency for Healthcare Research and Quality, estimated potential cost
savings in Medicare's prospective payment system when adverse events are
reduced. Dr. Zhan found significant savings but indicated that this may
be offset by the costs of safety systems and lost patient revenue.

### Findings

-   In employing CPOE systems, the use of professional services composes
    about one-third of the costs, and the core system represents about
    one-quarter of the costs.

-   The cost of a full CPOE system for an average-sized hospital is
    about \$3.2 million.

-   With increases in the size of hospitals, CPOE core system costs rise
    as professional services costs fall.

-   A CPOE system does not require an enormous information-technology
    system to be effective in improving patient safety.

-   For most cases, the diagnosis-related group (DRG) costs do not
    change in light of adverse events.

-   Hospitals may absorb much of the extra costs resulting from adverse
    events.

### Tools

-   CPOE technologies (core system, hardware, and software)

### Methodological and implementation challenges

-   Costs of introducing CPOEs include the core system, additional
    functions, software fees, hardware, and professional services.

-   It is unclear whether patient safety costs should be separated from
    the costs of patient care.

-   In applying safety systems, two costs apply: (1) costs of the safety
    system and (2) costs of lost patient revenue.

### Future applications, next steps

-   Determine whether safety systems will be driven more by regulations
    or market forces in the future.

-   Consider including safety measures in pay-for-performance models.

-   Determine the indirect costs and benefits of patient safety.

## ^■^ III. Techniques for Institutionalizing a Safety Culture ^■^ 

Bryan Sexton of The Johns Hopkins University School of Medicine,
reported on results of large multi-hospital surveys on satisfaction and
safety. Kerry Bommarito, of Washington University in St. Louis, provided
results from a safety-culture survey of employees in a large Midwest
healthcare system.

### Findings

-   There is great variability across work units in hospitals;
    safety/culture discussions must originate in each.

-   Familiarity improves predictable patterns of behavior and improves
    performance.

-   Executives and frontline workers often perceive teamwork
    differently.

-   Frontline workers need to feel respected.

-   In the Washington University survey, about 60 percent of respondents
    indicated that senior management had a clear picture of risks in
    patient care; and about 66 percent reported that senior management
    provided a climate that promoted patient safety.

-   In the Washington University survey, only a small number of
    respondents reported punitive results associated with errors.

-   Changing culture takes time, and must be measured before
    interventions are tailored to departments, job levels, etc.

### Tools

-   Unit-based safety programs such as Hopkins' CUSP

### Methodological and implementation challenges

-   In general, there is great variability across work units in a
    hospital.

-   Culture may vary across units and job levels.

### Future applications, next steps

-   Tailor interventions to units within an institution.

## ^■^ IV. Assessing Your Health Care Environment for Safety ^■^

James Battles from the Agency for Healthcare Research and Quality,
reported on the development, measures, and patient safety dimensions of
the Hospital Survey on Patient Safety Culture (HSOPSC). Barbara Horne
discussed the Indian River Memorial Hospital Center's administration of
HSOPSC to assess the organization's patient safety culture and how
survey results have led to positive changes within her organization.

### Findings

-   AHRQ funded the HSOPSC through the Quality Interagency Coordination
    Task Force (QuIC) to help hospitals assess the extent to which their
    cultures emphasize the importance of and facilitate patient safety,
    to open discussion of error, error reporting, and create an
    atmosphere of learning and improvement.

-   The safety culture is a product of individual and group values,
    attitudes, perceptions, competencies, and patterns of behavior.

-   A positive safety culture is characterized by communication based on
    mutual trust, shared perceptions of the importance of safety, and
    confidence in the efficacy of preventive measures.

-   The HSOPSC instrument measures errors, the perceptions of error, and
    many dimensions of the patient safety culture.

-   Managers must focus on facilitating communication between
    departments to foster a culture of safety.

### Tools

-   AHRQ's QUIC Hospital Survey on Patient Safety Culture (HSOPSC):
    <http://www.ahrq.gov/qual/hospculture>

-   New standard operational procedure instruments for long-term care,
    ambulatory care, and physicians

### Methodological and implementation challenges

-   There is a need for greater reliability in instruments (e.g., the
    HSOPSC instrument was well-tested for reliability).

-   Deciding whether to include clinical and non-clinical staff when
    administering the HSOPSC.

-   Garnering a suitable response rate with the HSOPSC (this challenge
    may be overcome by providing proper incentives for participants).

-   Obtaining OMB clearance for the HSOPSC.

### Future applications, next steps

-   AHRQ is creating a benchmarking, web-enabled database for
    institutional quality improvement.

## ^■^ V. Impact of Working Conditions on Patient Safety ^■^ 

Joel Weissman of Partners HealthCare Systems, Inc., described a current
study of the effects of crowded working conditions on adverse events in
hospitals using data from chart reviews. Nancy Donaldson of the
University of California, San Francisco, described an ongoing study of
the impact of nurse workloads on patient safety. Christopher Landrigan
of Children's Hospital Boston, reported on work he conducted with
Charles Czeisler that examined the relationship between sleep
deprivation and patient safety.

### Findings

-   Preliminary findings from the Weissman study suggest that the
    following factors vary and may be measured at various levels of
    aggregation: census and occupancy rates, diversion, average
    severity/complexity, average nursing acuity, total nursing staff,
    total non-nursing staff, ratio of RNs to non-RNs, and the number of
    patients per nurse.

-   The Weissman study may lead to new, inexpensive methods for tracking
    adverse events.

-   The University of California study found no relationships between
    the type of unit (medical, surgical, mixed) and hospital-acquired
    pressure ulcer risk or significant events (e.g., falls).

-   Landrigan and Czeisler's research demonstrates that reducing long
    work hours (i.e., \>30 consecutive hours) for interns in an
    intensive care unit reduces medical errors.

### Tools

-   A computerized adverse-event detection tool (CADeT)

### Dissemination strategies

-   Landrigan has been working with Massachusetts' and national
    legislators interested in his work, and one Massachusetts legislator
    has introduced legislation to limit residency hours.

### Future applications, next steps

-   The Donaldson and Weissman projects will be completed and published
    soon.

-   Seek additional ways to influence policy.

+----------+-----------------------------------------------------------+
|          | # E. EDUCATION AND TRAINING FOR SAFETY                    |
+----------+-----------------------------------------------------------+

Discussion in Track E, Education and Training for Safety, focused on
strategies for providing appropriate staff training on patient safety
practices. The track consisted of five sessions: *Informing Patients and
Families about Adverse Events*, *Does Team Training Make a Difference in
Delivering Safe Care*, *Health Care Education Tools 1 & 2*, and *Are
Simulations Effective Training Tools?*

High-level insights and findings from this track include:

-   It is more important to disclose errors than near misses when
    dealing with a patient's family.

-   Training can provide useful tools for disclosing errors to patients
    and families.

-   Successful team approaches used in the airline industry translate
    well to the medical fields and can be an effective way to reduce
    errors.

-   Video recordings of best practices can assist in reducing errors.

-   Simulators increasingly are demonstrating new ways to reduce medical
    errors but are costly and difficult to operate (thereby requiring
    additional research).

## ^■^ I. Informing Patients and Families about Adverse Events ^■^

Noel Eldridge of the Veterans Health Administration, discussed results
from a VA committee that considered the types of adverse events that
should be disclosed. Victoria Fraser of Washington University, discussed
results of focus groups and surveys that addressed the complex effects
of informing patients about adverse events. Lisa Rawn of the Uniformed
Services University of the Health Sciences, discussed the development of
a program using standardized patients (actors) to whom medical students
learn to disclose adverse events or other information.

### Findings

-   Adverse events should be disclosed to patients and their families.

-   Care must be taken to ensure that ADE disclosure does not further
    harm the patient.

-   An adverse event should be disclosed in the following
    situations: (1) if the effect was not previously discussed; (2) when
    the event necessitates a change; (3) when it places the patient's
    future health at risk; or (4) when it requires a procedure without
    the patient's consent (e.g., under anesthesia).

-   Patients generally are not interested in hearing about near misses
    but do want harmful errors to be disclosed.

-   Patients worry that health care workers hide errors.

-   Apologies and explanations to patients are important.

-   Physicians define errors narrowly (referring to some as unplanned
    events).

-   Physicians agree with the idea of full disclosure yet recognize
    barriers to disclosure (litigation, further harm to the patient,
    lost trust, and the difficulty of informing properly).

-   Physicians often do not disclose all the information that a patient
    wants to know.

### Tools

-   Standardized patients (actors) can be used to train medical students
    to disclose difficult or controversial information to patients in
    satisfactory ways and, in general, to communicate more effectively
    with patients.

### Methodological and implementation challenges

-   Some of the barriers to disclosure (litigation, further harm to the
    patient, lost trust, and challenges involved in informing patients
    properly) will remain.

### Dissemination strategies

-   The Veterans Administration offers a *Patient Safety Improvement
    Handbook* online
    ([www.va.gov/vhapublications](../www.va.gov/vhapublications))

### Future applications, next steps

-   Better/more training of physicians on properly informing patients.

-   Addressing the problem of liability.

-   Examining cultural differences that affect disclosure.

-   Considering the use of third parties to disclose adverse events.

## ^■^ II. Does Team Training Make a Difference in Delivering Safe Care? ^■^

Heidi King of the Office of the Secretary of Defense, described the
DoD's health care team coordination program, including the TeamSTEPPS
program. Lee Hilborne of the University of California, Los Angeles,
presented a history of team training, focusing particularly on the
airline industry, as it relates to patient safety.

### Findings

-   DoD's TeamSTEPPS program pointed out various needs, including the
    need to simplify a safety initiative, offer different levels of
    training, define metrics, engage senior leadership, provide regular
    coaching, and integrate the teamwork initiative with other safety
    initiatives.

-   Communication problems (verbal and handwritten) are responsible for
    most adverse events (about 60%).

-   Most adverse events are due to healthcare workers not following
    policies and procedures.

-   Some hospitals are implementing a team approach borrowed from the
    airline industry (Crew Resource Management Program) that has
    longstanding reputation for success.

### Tools

-   A medical Crew Resource Management Program (CRM)

### Methodological and implementation challenges

-   There are a number of factors that present challenges in the DoD
    environment, including: frequent deployments, obtaining buy-in from
    leadership, competing priorities, staff turnover, and challenges in
    transferring training.

-   A teamwork initiative must interact with other priorities and
    initiatives.

-   The multidisciplinary team approach includes a physician champion,
    nursing leaders, CEO support, and participation from all staff
    levels.

-   Transfer of training is a challenge.

### Future applications, next steps

-   Further adaptation and application of the CRM

## ^■^ III. Health Care Education Tools -- I ^■^

Pascale Carayon of the University of Wisconsin-Madison, presented
results of a program to evaluate the implementation of computerized
physician order entry systems (CPOEs) in intensive care units. David
Hunt of the Centers for Medicare & Medicaid Services, described the
Surgical Care Improvement Project to increase safety and reduce
morbidity and mortality. Marge Keyes of the Agency for Healthcare
Research and Quality, described the agency's Patient Safety Improvement
Corps, which is a partnership with the Veterans Administration and helps
states train their health departments. Steven Simon of Harvard Pilgrim
Health Care, presented three case studies that illustrate the potential
role of academic detailing in improving patient safety.

### Findings

-   The System Engineering Initiative for Patient Safety coupled with
    prospective human factors error analysis may reveal the effects of
    the use of CPOE technologies on safety, quality of care, end users
    (nurses, physicians, pharmacists), and costs.

-   The Surgical Care Improvement Project addresses the issue of
    infection, perioperative myocardial infarction, venous
    thromboembolic events, respiratory complications, and vascular
    access in end-stage renal disease.

-   The AHRQ/VA Patient Safety Improvement Corps funds state programs to
    identify medical errors, their root causes, and underlying system
    issues.

-   Academic detailing may target knowledge, skills, attitudes, and
    beliefs.

-   In a case study, group academic detailing helped to increase the use
    of safe medications and laboratory monitoring.

-   Academic detailing was not found to be effective as an adjunct to
    implementing computerized alert systems for prescribing (CPOEs).

### Tools

-   SEIPS and prospective human factors error analysis

-   Web-based curriculum (PSIC)

### Future applications, next steps

-   Develop and implement sustainable system interventions (PSIC).

-   The PSIC continues to train health department staffs in each state.

-   The PSIC will make a Web-based curriculum available by the end of
    2005.

## ^■^ IV. Health Care Education Tools--II ^■^

Christel Mottur-Pilson of the American College of Physicians (ACP),
described a program to educate physicians and students, using continuing
medical education (CME) presentations and train-the-trainer sessions to
increase safety awareness and behaviors. Colin Mackenzie of the
University of Maryland, presented an analysis of errors that led to a
loss of instrument sterility in the operating room, and a strategy of
reducing errors with the aid of video recordings and best practices.
Niraj Sehgal of the University of California, San Francisco, described
the AHRQ Patient Safety Network (PSNet), a Web-based portal containing
information, tools, and resources related to patient safety. Pamela
Mitchell of the University of Washington, Seattle, described an online
patient-safety curriculum/toolkit for medical professionals ("Faculty
Leadership in Interprofessional Education to Promote Patient Safety").

### Findings

-   Graduates of the ACP train-the-trainer program go on to become
    safety leaders in their communities.

-   Use of the best-practices video recording (Mackenzie) significantly
    reduced breaks in sterile techniques, empyema, needle sticks, and
    knife cuts for chest-tube insertion/removal.

-   The Patient Safety Network features lists of and links to safety
    news in journal articles, books, and newspapers. Site users may
    browse the site by subject areas, such as medication errors,
    diagnostic errors, and much more, and can customize the site to
    their areas of interest.

-   The FLIEPPS program also uses train-the-trainer sessions and a
    toolkit, and soon will offer both as online presentations. Those
    taking part in the curriculum go on to implement their own curricula
    in patient safety for health professionals.

### Tools

-   Video recordings of best practices (Mackenzie)

-   Tools offered on the PSNet and FLIEPPS Web sites (e.g., manuals)

### **M**ethodological and implementation challenges

-   Interest in self-assessment tools is low unless CME credit is
    provided (ACP).

-   The PSNet Web site must develop strategies to be helpful to a wide
    range of potential users/types.

### Dissemination strategies

-   The ACP program uses local chapters, booklets, and Web distribution.

-   The FLIEPPS program disseminates its messages in poster sessions and
    lectures at conferences.

### Future applications, next steps

-   A CME program for Web-based assessment.

## ^■^ V. Are Simulations Effective Training Tools? ^■^

George Blike of Dartmouth Hitchcock Medical Center, described his
group's work in human simulator research, intended to teach medical
students to respond to rare events in a real care setting. Kerm
Henriksen of the Agency for Healthcare Research and Quality, reviewed a
list of critical issues in simulation that need to be addressed. Mark
Bowyer of the Uniformed Services University of Health Sciences,
described the features and programs of the National Capital Area Medical
Simulation Center, which houses one the largest collection of medical
and surgical simulators in the country.

### Findings

-   The Dartmouth Center's human simulator can respond qualitatively and
    quantitatively (and realistically) in an emergency resuscitation
    situation.

-   Use of the Dartmouth Center's simulation system led to the discovery
    of deficiencies in the hospital paging system.

-   Costs related to simulation are falling, and technologies are
    improving.

### Tools

-   The Dartmouth Center's human simulator

-   Various simulators at the NCA Medical Simulation Center

### Methodological and implementation challenges

-   The Dartmouth Center's simulator costs \$120,000 and took one year
    to function properly.

-   The use of a simulator in the real care setting involves important
    legal issues.

-   Issues related to integrating the technology into a curriculum.

-   The need to address issues of validation and verification.

-   The need to involve end users early in the design of simulators.

-   The need to market the importance of simulators to quality
    improvement committees that in turn may incorporate them into
    quality-control processes.

### Future applications, next steps

-   Consider problem-solving simulations.

-   Emphasis should be placed on using simulators for training purposes.

-   Boards should require simulation experience for certification
    purposes.

-   Involve end users early in the design of simulators.

-   The healthcare industry should strongly encourage debriefings on
    methodologies subsequent to using simulators.

-   There are a number of challenges posed by the use of simulators,
    including: How do we define design features? What types of
    procedures are most appropriate to simulate and train on? What
    sensory discriminations need to be included? Which system
    malfunctions and other determining conditions should be included?
    Who develops the scenarios? And finally, what does improvement look
    like?

+----------+-----------------------------------------------------------+
|          | # F. USING REPORTING SYSTEMS EFFECTIVELY                  |
+----------+-----------------------------------------------------------+

The final track, Track F, Using Reporting Systems Effectively, assessed
various applications of data and reporting systems to reduce adverse
events. This track consisted of five sections: *Using Data Systems to
Identify Potential Harm 1 & 2*, *Using Reporting Systems Data for Action
1 & 2*, and *Using Reporting Systems to Engage Consumers in Patient
Safety*.

High-level insights and findings from this track include:

-   Automated data systems and surveillance systems are useful at
    tracking and studying errors.

-   Benchmarking and quality improvement tools are available from AHRQ
    to improve patient safety programs.

-   Standardization in reporting can be helpful across systems.

-   Consumer involvement in reporting errors and managing their own care
    can be a helpful tool in reducing errors.

## ^■^ I. Using Data Systems To Identify Potential Harm -- I ^■^

Harold Kaplan of Columbia University focused his discussion on using
data and real-time reporting systems to avoid medical errors. Brian
Strom of the University of Pennsylvania Medical Center, described the
comprehensive efforts and new programs that his hospital has instituted
to monitor and reduce adverse events and maintain therapeutic quality
assurance.

### Findings

-   A real-time event reporting system, such as the MERS-TH, facilitates
    corrective actions by analyzing event rates; how events were
    discovered; types of events; outcomes of events; and by estimating
    probabilities of recurrence.

-   An automated system may reveal similar events in data sets by
    measuring who, what, where, and when events occurred, and the
    severity associated with events.

-   The University of Pennsylvania Medical Center employed a
    multi-pronged effort to reduce events, including a Drug Use and
    Effects Program (focusing on medications), an Adverse Drug Reaction
    Program (to monitor ADRs), a Drug Use Evaluation Program (analyzing
    and developing criteria for appropriate use) and a cost-containment
    program.

### Tools

-   Automated data analysis programs

## ^■^ II. Using Data Systems To Identify Potential Harm--II ^■^

Wu Xu of the Utah Department of Health, discussed ways to identify
potential harm using population morbidity and mortality data. Edward
Dunn of the Veterans Health Administration National Center for Patient
Safety (NCPS), presented results based on the application of data
systems to increase safety.

### Findings

-   ICD-9 and ICD-10 classifications may be used for population-based
    surveillance of healthcare-associated patient harms.

-   The NCPS uses Safely Pointing Out Trouble (SPOT) software to
    facilitate reporting and data analysis, and uses the Patient Safety
    Reporting System (PSRS) to collect anonymous reports of adverse
    events and produce feedback.

-   The NCPS systems have been used successfully to ensure correct
    surgery and increase hand hygiene.

### Tools

-   ICD-9 and ICD-10 morbidity and mortality data

-   Software for analyzing data

### Methodological and implementation challenges

-   In Utah, some patient safety sentinel events are excluded from
    reporting requirements; therefore, they are unavailable for data
    analysis.

## ^■^ III. Using Reporting Systems Data for Action--I ^■^

Ernest Moy, Agency for Healthcare Research and Quality, discussed the
goals, measure topics, databases, and key findings of AHRQ's National
Healthcare Quality Report (NHQR) and the National Healthcare Disparities
Report (NHDR). Beth Kosiak, Agency for Healthcare Research and Quality,
discussed AHRQ's Consumer Assessment of Health Plans Surveys (CAHPS)
project and its use in the National Healthcare Quality and National
Healthcare Disparities Reports as an indicator of patient centeredness.
Shirley Kellie, Centers for Medicare and Medicaid Services, discussed
how individual and organizational memory relates to using reporting
systems. Mark Keroack, Agency for Healthcare Research and Quality,
described the UHC Patient Safety Net, a Web-based event-reporting system
in which more than 25 large institutions participate.

### Findings

-   AHRQ's 2004 NHQR and NHDR reports found that gaps in information
    exist for specific conditions and across populations; a continuing
    gap exists between best possible care and actual care; and pervasive
    disparities in care persist across the health care system (and are
    particularly racial and socioeconomic in nature); however, quality
    overall (safety, timeliness, and effectiveness) has improved.

-   The 2004 NHQR and NHDR reports indicated that quality of care is
    improving by about 2 percent each year.

-   CAHPS measures patients' experience rather than satisfaction to
    avoid ceiling effects and to learn more detail about important
    aspects of patients' experiences.

-   Groups may submit de-identified data to the National CAHPS
    Benchmarking Database (NCBD) and receive free customized reports,
    including national, regional, and health-plan averages.

-   In the area of safety, the Hospital CAHPS includes questions about
    medications, and the ICH-CAHPS includes questions about the use of
    gloves and the monitoring of dialysis machines.

-   Near-miss reporting has the potential of building organizational
    memory and improving the reliability of a practice.

-   The UHC Patient Safety Net may be used with various methodologies to
    facilitate improvements in safety.

-   In a survey of users, about 59 percent of manager-respondents
    indicated that they made changes in policies and practices as a
    result of UHC Patient Safety Net data.

-   As agents of change, managers must prevent the build up of "data
    graveyards," and establish policies, training, and education
    programs.

-   Decreasing barriers to reporting enhances reporting and increases
    organizational learning.

-   Sharing data leads to the identification of problem areas and
    innovative solutions.

-   Viewing data in the aggregate is one key to invoking organizational
    change.

### Tools

-   AHRQ offers resources at
    [www.qualitytools.ahrq.gov](http://www.qualitytools.ahrq.gov/);
    [www.qualitymeasures.ahrq.gov](http://www.qualitymeasures.ahrq.gov/);
    and [www.talkingquality.ahrq.gov](http://www.talkingquality.gov/)

-   AHRQ offers *Your Medicine: Play it Safe* (brochure) and the
    *Hospital Survey on Patient Safety Culture* (to establish the
    baseline of the culture), and a spectrum of surveys on quality and
    safety

-   National CAHPS Benchmarking Database (NCBD):
    <http://ncbd.cahps.org/>

-   CAHPS technical assistance and products are available at
    [www.cahps-sun.org](../www.cahps-sun.org)

-   Medical Events Reporting System (MERS-TH) and the Eindhoven Causal
    Classification System

-   The UHC Patient Safety Net

-   AHRQ's Web-based clearinghouse provides practical tools for
    assessing, measuring, promoting, and improving the quality of
    Americans\' health care
    ([http://www.qualitytools.ahrq.gov](http://www.qualitytools.ahrq.gov/))

### Methodological and implementation challenges

-   In using the PSN, users should be aware of possible reporting bias,
    relative rates, and misclassified data.

### Future applications, next steps

-   AHRQ's new \$1 million initiative to partner with state policymakers
    seeks to improve 5 to 10 quality measures, using a new communication
    and action infrastructure and the sharing of practices.

-   Additional areas of study will be added to the CAHPS survey.

-   Investigate the potential to compare data from the CAHPS surveys to
    AHRQ's Hospital Survey on Patient Safety Culture (HSOPSC).

## ^■^ IV. Using Reporting Systems Data for Action--II ^■^

John Gosbee of the Department of Veterans Affairs, described work at the
VA's National Center for Patient Safety, examining causes of adverse
events and developing tools (including standard language) and products
to address the issue. Stephen Raab from the University of Pittsburgh
Medical Center, described his AHRQ-funded work examining pathology
errors, especially in cancer diagnosis. Diane Cousins of the United
States Pharmacopeia, reviewed her organization's MedMarx reporting
program, which collects (anonymous) instances of adverse drug events,
analyzes the data, and reports results back to hospitals.

### Findings

-   Biases across institutions limit error analysis.

-   Double-viewing by two physicians may actually increase errors
    (Pittsburgh study of cancer diagnosis).

-   U.S. Pharmacopeia's program has been associated with a rise in
    errors discovered and reduction in errors affecting patients.

-   U.S. Pharmacopeia's program found instances of omission and
    prescribing errors to be the most common types of adverse events.
    The main cause has been incorrect administrative technique (for
    example, crushing time-release tablets), with distraction suggested
    as a contributing factor.

### Tools

-   Standard language (keywords) to use in narratives about and analysis
    of adverse events

-   A Web database to collect adverse events

-   Labeling strategies for drug containers

### Methodological and implementation challenges

-   Roadblocks in information technology include issues of security,
    usability, and scalability.

-   Optimal procedures are rarely shared across institutions, and
    hospitals employ very different processes.

-   The time needed to cull knowledge from data and to train people is a
    challenge.

-   Institutions are only able to absorb a certain number of changes at
    once.

### Dissemination strategies

-   Courses, alerts, advisories (the VA)

### Future applications, next steps

-   The VA is working to define types of events and relevant reports
    more appropriately.

## ^■^ V. Using Reporting Systems To Engage Consumers in Patient Safety ^■^

Saul Weingart of Beth Israel Deaconess Medical Center, discussed
possible roles of the patient in identifying and reporting medical
errors. Martin Hatlie of Partnership for Patient Safety, described the
Consumers Advancing Patient Safety (CAPS) program, which is supported by
AHRQ. Susan Sheridan presented personal stories of medical errors that
affected the care of her husband and her son and described barriers that
prevent consumers from working with the medical system to increase
safety.

### Findings

-   Dr. Weingart noted a study that found 44 percent of preventable
    adverse drug events occurred when doctors failed to act; and 28
    percent of adverse drug events occurred when patients failed to
    inform their doctors of symptoms.

-   In one study, few patient-reported incidents were reported in the
    medical record, and none were submitted to the hospital's incident
    reporting system.

-   A randomized controlled trial of an intervention involving a drug
    safety handout and medication list provided to patients produced no
    significant difference between intervention and control groups
    regarding subsequent adverse events.

-   Among other goals, the CAPS program seeks to include health care
    consumers in event reporting activities.

-   Involving consumers in incident reporting leads to improvements in
    community relations, consumer education, feedback to health care
    organizations, opportunities to prevent harm, and less exposure to
    litigation.

-   When the incidence of kernicterus (brain damage from untreated
    neonatal jaundice) reappeared in the early 1990s, new efforts to
    report, initiated by consumer pathways, helped to reduce and
    eliminate its occurrence.

### Tools

-   A personal Web site ("Patient Site") for the patient, through which
    patients can report on results and timing of medications, receive
    messages from the medical team, and view personal hospital records

### Methodological and implementation challenges

-   Advancing consumer involvement in medical error reporting carries
    with it many challenges

-   Obstacles to reporting the kernicterus episodes in the early 1990s
    included difficult diagnosis, litigation strategies, and public
    relations concerns.

### Dissemination strategies

-   The CAPS program offers information on the Web at
    [www.patientsafety.org](http://www.patientsafety.org/)

### future applications, next steps 

-   Establish roles for consumers; create consumer advisory bodies.

+---------------+------------------------------------------------------+
|               | # CHAPTER TWO:                                       |
|               |                                                      |
|               | # PATIEN                                             |
|               | T SAFETY/HEALTH INFORMATION TECHNOLOGY CROSSOVER DAY |
+---------------+------------------------------------------------------+

On Wednesday, June 8, AHRQ's Patient Safety Research Coordinating Center
and Health Information Technology Resource Center shared information
during the conference's "crossover day." The day also highlighted
grantee's accomplishments and brought attention to policy issues
involved in addressing patient safety and Health IT needs. Highlights of
this day include keynote addresses from AHRQ's Director Carolyn Clancy,
Department of Health and Human Services Secretary Michael Leavitt, the
Honorable Nancy Johnson (R-Connecticut), Reed Tuckson, Senior Vice
President of Consumer Health and Medical Care Advancement for
UnitedHealth Group, as well as a Congressional staff panel and a media
panel. Details of Crossover Day activities are presented below.

## ^■^ Opening Remarks By Carolyn Clancy, Director, Agency for Health research And Quality ^■^

Dr. Carolyn Clancy, Director, Agency for Healthcare Research and
Quality, set the tone for an exciting day of keynotes and presentations
from leaders in health IT and patient safety. She emphasized the
connection between health IT and patient safety, noting that the
Institute of Medicine's landmark 1999 report, To Err is Human,
fundamentally changed American's perceptions about the safety and
overall quality of their everyday health care.

AHRQ has been uniquely involved in improving health care safety, through
work that is specific to patient safety and health IT. Since 2001, AHRQ
has funded more than 100 patient safety projects, especially research on
medication safety, communication with patients, intensive care issues,
and fatigue among hospital staff. In addition, Dr. Clancy announced the
award of another \$8 million to fund 15 new patient safety projects
(Partnerships in Implementing Patient Safety) aimed at implementing
proven approaches.

On the health IT side, Dr. Clancy noted that President Bush has called
for electronic records for Americans within 10 years. Health IT is a
national priority, and AHRQ is helping to make it a reality with the
portfolio of health IT research it funded in 2004 and the establishment
of the National Resource Center for Health Information Technology.

Dr. Clancy closed by offering the following formula for health care
improvement:

-   Connect health records.

-   Build smart systems.

-   Put the patient at the center of care.

-   Put prevention at the center of treatment.

## ^■^ Keynote Address: Michael Leavitt, Secretary, United States Department of Health and Human Services ^■^

Secretary Leavitt expressed his strong belief in the need to advance
electronic medical records and other aspects of health IT. "This is a
very big deal," he said. "It will affect every American." He noted that,
earlier that week, he had announced the formation of a national
collaboration and four requests for proposals to advance efforts to
create electronic health records for most Americans within 10 years.

The American Health Information Community (AHIC), which Leavitt will
chair, will have 17 members, including representatives of the physician
and hospital community, the insurance industry, and federal agencies,
including Medicare, Medicaid, the Indian Health Service and the Food and
Drug Administration. Secretary Leavitt noted that some standards on
interoperability could be ready within a year. Early deliverables from
the new panel will include standards relating to prescription drug data,
laboratory results, and computers systems that can track the emergence
of a pandemic or a bioterror attack.

Secretary Leavitt sees three roles for the federal government: (1)
convene; (2) be an early adopter; and (3) provide seed money to assure
that the fundamental elements needed to secure interoperability are in
place. On all three levels, HHS is moving forward at a rapid pace. In
the end, the Secretary noted that he aspires to four outcomes: (1)
achieve better quality care; (2) lower medical costs; (3) reduce medical
mistakes, and (4) diminish the "hassle factor" in health care.

## ^■^ Keynote Address: Honorable Nancy Johnson (R-CT) ^■^

Congresswoman Nancy Johnson (R-CT), a staunch supporter of health
information technology and Medicare modernization, delivered a
compelling speech.

Mrs. Johnson pointed out that it is difficult for laypeople to
understand how technology can lower costs, improve quality and
personalize services, and that we are fortunate to have many high-level
officials who understand this concept and are committed to improving
technology.

One issue that Mrs. Johnson has specifically dealt with involving health
IT is Medicare modernization. She found that technology is the key to
moving from a disease/illness treatment model to a chronic
disease/prevention model. Using health IT has had a positive impact on
Medicare policy and law, for example by improving many aspects of the
system.

Mrs. Johnson proposed that government focus more on moving health
technology forward, rather than setting national laws regarding health
IT. Her fear is that Congress may not be able to act as quickly as the
advances of technology, and thus new laws quickly become outdated. A
public/private partnership, according to Mrs. Johnson, would be ideal
because it could be more flexible, visionary and disciplined.

## ^■^ Congressional Staff Panel on Health Policy ^■^

Scott Young of AHRQ moderated a panel of Congressional staffers that
provided a legislative view of current health policy, Health IT and
patient safety. Panelists for this session included Liz Scanlon-Hall
from the Office of Bill Frist (R-TN), Dave Fisher from the Office of
Judd Gregg (R-NH), David Bowen of the Senate Health Education, Labor and
Pensions Committee and the Office of Ted Kennedy (D-MA), Nandan
Kenkeremath of the House Energy and Commerce Committee, and Kathleen
Weldon from the Majority staff of the House Ways and Means Health
Committee. Mr. Young kicked off the discussion by asking about the
appropriate federal role in advancing health IT.

Key insights from this panel discussion included:

-   There is broad bipartisan support for improving our health IT
    infrastructure but some dissent regarding the role of the federal
    government and specifically, Congress.

-   The government can serve as both a partner and a purchaser of health
    IT.

-   One possibility for government involvement is to create incentives
    for implementing and improving health IT infrastructure.

-   It is crucial that the government not serve as an impediment to
    health IT progress.

-   Health IT advancements must take HIPAA and other state-level privacy
    laws into account and must be flexible enough to comply with these
    regulations.

## ^■^ Innovations in Health IT and Patient Safety ^■^

Deborah Queenan and Scott Young of AHRQ moderated a panel discussion
showcasing the outstanding accomplishments of AHRQ Patient Safety and
Health IT grantees. Featured grantees were Gail Bellamy of West Virginia
Medical Institute/Quality Insights, Kevin Johnson of Vanderbilt
University, Hal Kaplan of Columbia University and Jan Root of the Utah
Health Information Network.

Key insights and lessons learned from this panel include:

-   Strong public and private partnerships are essential for widespread
    rollout of programs.

-   Learning from technology implementation failures is as important as
    learning from implementation successes.

-   A reporting system must be able to provide timely feedback or it
    will not be useful.

-   Direct messages are the key components of a RHIO business model.

## ^■^ Keynote: Reed Tuckson, Senior Vice President, UnitedHealth Group ^■^

Reed Tuckson, Senior Vice President of Consumer Health and Medical Care
Advancement for UnitedHealth Group delivered a motivating speech about
powerful advances in health IT used to improve quality, access, and cost
of care.

Dr. Tuckson described five factors that will affect the ability of
health IT to address quality of care, access, and cost, including:

-   Escalation in health care costs.

-   Care that does not follow scientific evidence.

-   New knowledge, drugs and technology.

-   Consumptive society.

-   Aging and chronic illness.

According to Dr. Tuckson, health IT has the ability improve the health
infrastructure by greatly reducing costs through streamlining and
reducing administrative burdens, providing accurate and updated
information about practice recommendations and guidelines, improving
patient record availability through EHR and coordinating care more
effectively.

## ^■^ Behind the Scenes: How the News Media Covers New Developments in Patient Safety and Health IT ^■^

Dr. Carolyn Clancy facilitated a panel discussion of health IT and
patient safety media coverage. The panel represented diverse aspects of
the news media and was comprised of David Brown from The Washington
Post, John Hamilton from NPR, Scott Weier from iHealthBeat, and Lauran
Neergaard from the Associated Press.

Panelists addressed the difficulty of bringing advancements in patient
safety and health IT to the attention of editors and the public. For
example, national news services with a strong health interest may refer
a local-based story to the local news bureau that may not share an
interest in disseminating health-related stories. Furthermore, the types
of stories generated by patient safety/health IT research advancements
may not contain the elements valued by the press, such as human drama.

Several tips were suggested that may increase the likelihood that a
story will be published include:

-   Provide data to support any claims;

-   Use a story with wide interest to the public that can be
    personalized;

-   A story with a tie-in besides health (such as IT-business) might
    have wider reach; and

-   Timing can be very important---if President Bush makes a speech
    mentioning patient safety, the media will be more responsive to that
    story.

## ^■^ Strategic Framework for Improving Health Care Through HIT: David Brailer, National Coordinator for Health Information Technology ^■^

Dr. Brailer began by underscoring the special partnership between AHRQ
and the Office of the National Coordinator for Health Information
Technology (ONCHIT) to advance health IT in the United States. This
initiative is moving forward very rapidly. The process, he stressed,
will not be a regulatory-driven process, but will come from the ground
up. The federal government's role is to provide boundaries, guidelines,
resources, and tools, and Brailer emphasized that they "are the people
that are going to make this happen."

Improving patient safety and reducing medical errors are at the root of
why health IT is important. "Technology is a means to an end," he
observed, and the way that technology is used must be patient-centered.
"How do we make information change the way consumers engage health care,
learn about their health status and their options, start looking out for
their own treatment choices, and be able to manage their own care in a
way that is similar to how we manage other things in our daily lives?"

Dr. Brailer identified "two huge challenges" to achieving the vision for
health IT: (1) interoperability and (2) adoption of new technologies.
Although these issues are being addressed in different ways, it will
take time to overcome these challenges and fully implement health IT. On
interoperability, the new American Health Information Community
announced by Secretary Leavitt will create a "unified scheme" tying
together various efforts on standards and certification. In addition,
Dr. Brailer cited three things in particular that must happen to achieve
full implementation of health IT:

-   The cost of the new technologies must come down;

-   A convincing business case for health IT must be made; and

-   The financial, managerial, and technical risk of purchasing new
    technologies and systems must be reduced.

He concluded by reminding the audience that private sector action is
critical for government efforts on health IT to succeed. "You all need
to think of yourselves as entrepreneurs."

+---------------+------------------------------------------------------+
|               | # CHAPTER THREE:                                     |
|               |                                                      |
|               | # HEALTH INFORMATION TECHNOLOGY                      |
+---------------+------------------------------------------------------+

## ^■^ HEALTH Information Technology in 2005 ^■^

The first Annual Meeting for AHRQ's Health Information Technology
grantees provided a snapshot of the work of current Health IT grantees
and served as a conduit for brainstorming and sharing among providers
and systems seeking to further their Health IT capacity.

+---------------+------------------------------------------------------+
|               | # SESSIONS AND FINDINGS                              |
+---------------+------------------------------------------------------+

The conference was arranged into seven tracks consisting of four
sessions each. Each track was lead by one or two track coordinators. The
tracks were:

A.  The Intersection of Health IT and Patient Safety

B.  Health Information Exchange

C.  Assessing Value and Evaluating Health IT

D.  Public Trust in Health Information Systems: Handling Privacy,
    Security and Related Issues

E.  Coordinating Care Using IT and Telehealth

F.  Health IT Nuts & Bolts: Tackling the Technical Issues

G.  Funding and Managing Health IT Projects

+----------+-----------------------------------------------------------+
|          | # A. THE INTERSECTION OF HEALTH IT AND PATIENT SAFETY     |
+----------+-----------------------------------------------------------+

Renowned patient safety experts and AHRQ grantees David Bates and Tejal
Ghandi, of Harvard Medical School and Partners Health Care, oversaw this
track, which spanned across the five days of the meeting. Sessions in
this track primarily used case studies to translate practical
applications of health IT and its impact on patient safety and quality
of care. Presenters discussed tools that had an impact on medication
safety such as CPOE, barcoding and eMAR as well as tools used to improve
transfusion safety. The sessions went further to elucidate successful
strategies for and barriers to the successful implementation of these
tools, emphasizing that technology is not a panacea and that a keen
understanding of human factors and workflow is key to an
implementation's success.

High level insights and findings from this track include the following:

-   Paying attention to human factors is critical; it is important to
    involve users from the beginning of the planning process and to
    conduct usability testing.

-   It is important to garner a broad base of support for the
    implementation of health IT tools, especially from senior leadership
    and clinical champions.

-   System modifications after implementation should be expected. There
    should be plans for mid-course corrections, improvements and
    workarounds.

-   Robust communication strategies must exist to communicate with
    front-line staff. In creating such strategies, it is important to
    set reasonable expectations and promote successes.

-   Automation can illuminate pre-existing bad practices; it is
    important to look for unanticipated consequences and new errors
    caused by the technology.

-   Health IT provides a way to standardize and structure data to
    improve measurement and benchmarking capabilities.

-   Future Study: There is a need for greater support for evaluation and
    implementation studies.

## ^■^ I. Highlights of AHRQ's Patient Safety Portfolio ^■^

Several AHRQ grantees offered a look inside their projects, highlighting
the tools and functionality that proved successful, as well as applied
strategies for overcoming barriers to improving patient safety through
health IT. Steven Simon and Micky Tripathy (Massachusetts e-Health
Collaborative) detailed aspects of their strategy in carrying out the
vision of a statewide e-health collaborative, followed by Brian Strom
(University of Pennsylvania Medical Center) who conveyed lessons learned
from his projects' look at the occurrence of errors along the pathway of
medication use. Eric Thomas (University of Texas --Houston Medical
School) mainly discussed survey instrumentation his projects employed to
assess attitudes towards patient safety and health IT. Finally, Hal
Kaplan (Columbia University) provided an overview of the event reporting
system that has been rolled out in participating New York-area
hospitals.

### discussion points

-   Strategies to improve patient safety through a regional consortium.

    -   Vision: providing tools for better care, incorporating them into
        clinical practice, and working towards financial sustainability.

    -   Who are the players and stakeholders?

    -   How is the organization/initiative governed and structured?

    -   How do you set up pilot communities to foster IT adoption?

    -   Is it effective? How to demonstrate value?

-   Strategies to improve patient safety by reducing errors in the
    medication use process.

    -   Study approaches and designs to look at medication use process.

    -   Establishing ideal conditions for technology effectiveness.

    -   Measuring the patient safety climate and teamwork culture.

    -   Assessing attitudes: survey design and administration.

-   How to promote a patient safety culture.

    -   How much of a role does culture play in patient safety?

    -   Implementing a standardized error reporting system

    -   System design and infrastructure.

-   How to control information access, confidentiality.

    -   Adapting technology to workflow, institutional changes.

### key challenges

-   Establishing financial sustainability for IT adoption, identifying
    ongoing resources.

-   Convincing vendors to collaborate in order to facilitate
    inter-institutional data sharing.

-   Understanding existing medication use and other workflow.

-   Understanding the impact of technology on workflow.

-   Adapting the technology to the existing environment, avoiding
    IT-induced error.

-   Understanding how to foster and measure the patient safety culture.

-   Time expenditure and opinions of perceived ineffectiveness can
    hinder effective reporting.

-   Mitigating tension between adverse event reporting accessibility and
    confidentiality.

### key insights/lessons

-   It is necessary to demonstrate and disseminate the value of IT
    implementation efforts.

-   Technology should not be utilized as a substitution for people.
    Human factors analysis is critical to ensuring the technology's use
    and positive impact, regardless of the system or version.

-   Continuous system evaluation and quality improvement activities are
    critical.

-   There is no one patient safety or teamwork culture dominating a
    hospital.

-   Executive walkarounds can be effective in improving the patient
    safety climate when implemented widely.

-   Reporting systems should be built with the user in mind -- the users
    should be able to gather data without understanding the database
    design.

## ^■^ II. Translating Health IT Into The Practice Of Patient Safety ^■^

The AHRQ grantees in this session discussed how their IT projects
improved patient safety in various settings from the ED to inpatient
care to the ambulatory setting. Harry Selker (Tufts-New England Medical
Center) provided an overview of their use of predictive instruments for
decision support to reduce errors in emergency cardiac care, followed by
Michael Waggoner (Cleveland Clinic Health System East) who described
their approach to increasing physician involvement in the implementation
of CPOE, which he labeled "CPOM" as they want physicians to do more than
just enter orders. Fred Rachman and his team (Alliance of Chicago
Community Health Services) described a multi-stakeholder collaborative
approach to implementing EMRs in the ambulatory setting with a focus on
measurement sets and measures for passive and active decision support.

### discussion points

-   Successful implementation of an EMR includes an organizational
    vision, a necessary commitment from all stakeholders, and a
    dedicated project team.

-   CCHS-East hired a physician part-time to serve as a physician
    advisory to define doctor workflow, guide the system design, review
    medical staff bylaws and policies to determine the impact of the
    system, lead a steering committee, and drive communication.

-   It is important to identify the patient safety measure or indicator
    first and then determine how IT can be utilized to improve the care
    practices around this measure.

-   At Tufts-New England Medical Center, patients with ECG abnormalities
    and ST segment elevation were often sent home by the ED physician.
    This drove the need for a design of a predictive instrument that
    prints out with the ECG to help drive clinical decision-making.

-   At Alliance, the practitioners were having difficulties accessing
    patient information due to the large volume of patients and limited
    time for interaction. The team decided to look at IT to assist in
    providing access to patient information.

-   It may take a few iterations to develop a tool that providers will
    adopt and use.

### key challenges

-   Developing a design that will be acceptable to multiple providers is
    always a challenge. It may take much more time up front in the
    design and rollout to develop approaches that will increase
    adoption.

-   Just because functionality is available does not mean it will be
    utilized. Functionality must be intertwined with the physicians work
    practices.

-   Quality measurement has not been done on a wide scale using an EMR.
    Timelines and resources are always a challenge.

### key insights/lessons

-   Many patient safety issues that compromise patient care are "health
    system issues," not just problems at the hospital level.

-   Create and define the measures that you will utilize the technology
    to evaluate and monitor.

-   Understand the culture and practice patterns of your providers; the
    implementation of healthcare IT may require multiple approaches to
    drive towards 100% adoption.

-   Providing access to information drives passive decision support, but
    building active decision support into your IT system will deliver
    higher levels of functionality for patient safety.

-   Requirements for active decision support include a groundwork laid
    before implementing, and an evidence-based set of protocols that is
    acceptable to the doctors using it.

-   One needs to pay attention to not only the metrics, but how to get
    the data for the metrics, leveraging shared infrastructure and
    common goals.

-   Diligent project management is key to success.

-   A big aspect of convincing providers that your data is accurate are
    that they must be specified to the way they conduct their practice.

## ^■^ III. Improving Medication Management and Blood Product Administration ^■^

The AHRQ grantees in this session provided overviews of their projects
in the areas of medication management and blood product administration.
Susan Horn (Institute for Clinical Outcomes Research) discussed the
medication management and care delivery processes in a nursing home
setting around the management of pressure ulcers, and how healthcare IT
can be used to improve this process along with workflow redesign. Peter
Kilbridge (Duke University Health System) described Duke's goal of
establishing a computerized system and methodology for detecting common
adverse drug events and managing interventions. Paula Edwards (Georgia
Tech Children's Hospital / Children's Healthcare of Atlanta) described
the implementation of IT to reduce medication errors in a private and
academic pediatric setting, and Lee Carmen (University of Iowa Hospital
and Clinics) discussed their project of improving blood products
administration using wireless and barcode technology.

### discussion points

-   Healthcare IT system implementation alone does not drive success and
    improvements in patient safety; it must be coupled with a workflow
    process redesign.

-   To ensure that an implementation meets patient safety goals, one
    needs to get frontline users involved and keep them involved.

-   Conducting a baseline assessment of your measures/metrics is key to
    defining your project goals and objectives and measuring the
    benefits. Analysis of the system data and re-measurement is
    necessary throughout the project to refine your system design,
    implementation approach, or work practices.

-   Know your end-users and design the transition from old to new
    accordingly.

### key challenges

-   A major challenge during your implementation may not be the
    technology and adoption.

-   For barcoding of wrist bands, one needs a band that is waterproof,
    robust, non-allergenic, etc.

-   How to manage printout of barcode labels? Should the barcode be
    unique for each wristband?

-   How to clean a computer cart?

-   Do the trays used by the pharmacy match the drawers on the computer
    carts on the floors?

-   Need to look into work arounds by end-users: why are they doing them
    and what changes need to be made to avoid the workarounds?

-   Developing organizational consensus and common definitions across
    hospitals is a challenge.

### key lessons/insights

-   Workflow redesign coupled with technology implementation is the key
    to improving patient safety.

-   Monitor your system data regularly to determine the needed changes
    in work practices or system design.

-   Need to communicate tangible results achieved towards your goals.

-   Surveillance systems detect ADEs at a higher rate than voluntary
    systems.

-   Barcoding can be more effective than the manual process for blood
    products administration.

## ^■^ IV. Ask the Experts: Patient Safety and Health IT ^■^

This panel session facilitated by Tejal Gandhi (Harvard Medical
School/Partners Health Care) included David Bates (Brigham and Women's
Hospital), Bill Galanter (University of Illinois Medical Center --
Chicago), and Emily Welebob (eHealth Initiative Foundation). The
panelists provided an overview of their focus on patient safety and
health IT followed by Q&A from the audience.

### discussion points

-   The literature suggests override of 80 to 90% of alerts in the
    outpatient setting.

-   Set up a system to flag the individual types of alerts and look at
    how often they go off and how often people respond by interaction.
    Look at these rates over time and refine the alerts iteratively.

-   One dimensional bar-coding may be too long for the small wrist of
    infants; two dimensional bar-coding is smaller, but may be more
    irritating to the skin.

-   RFID is another option to bar-coding.

-   Health IT can cause people to make errors, but studies often do not
    measure error rates before implementation, so we do not know if the
    error rate is higher or lower using the CDS system.

-   Need to devote proper resources to going through your IT system to
    find out where it encounters difficulties and address them.

-   Question your vendor and see where the system works and doesn't.
    Have the alerts provided by the vendor been tested in a clinical
    environment previously?

-   Rural practices have even more challenges when it comes to resources
    compared to the larger institutions.

### key challenges

-   Resources to design and develop efficient alerts.

-   Pediatric rules and alerts are more complex and some systems may
    present challenges.

-   Driving support for Health IT/CDS has been challenging with recent
    press around IT causing medical errors.

### Key Insights/Lessons:

-   Efficacy of alerts -- important not to deliver too many alerts and
    displaying them so that clinicians are not irritated.

-   Leverage the work of your peers -- 10 hospitals in Chicago using the
    same CDS vendor are tackling issues as a group.

-   Important to measure your error rate prior to system implementation
    to prove the benefits of CDS

+----------+-----------------------------------------------------------+
|          | # B. HEALTH INFORMATION EXCHANGE                          |
+----------+-----------------------------------------------------------+

Dr. Mark Frisse, Director of Regional Informatics Programs at the
Vanderbilt Center for Better Health, and Dr. Jan Root, Assistant
Executive Director of the Utah Health Information Network (UHIN) chaired
this track. They brought their extensive expertise in developing
state-wide and regional health information infrastructures to bear on
this track. Panel presentations identified critical sustainability and
success factors, issues, challenges, the lessons learned and pitfalls of
developing health information organizations through various stages. Over
a period of two days, four sessions addressed: *HIE Planning: How to Get
Started*; *HIE Organization and Governance Approaches and Models*;
*Perspectives from the Front Lines*; and *Implementation and Beyond*.

High level insights and findings from this track include the following:

-   The potential for health IT and the commitment to getting health IT
    into place has never been as well-realized and as broadly understood
    as it is today.

-   New models of health information exchanges are emerging in order to
    accelerate the pace of health IT adoption and implementation.

-   If health IT is to be realized and adopted throughout the health
    care system, the engagement of trusted third party payers is
    critical.

-   Health IT efforts must bring value to all if we want broad and ready
    access to resources.

-   We need to develop stronger communities and more information on
    successes and failures in order to achieve interoperable networks
    that deliver sophisticated, patient-specific information whenever
    and wherever needed, securely and privately.

-   The need for a strong Web site is critical in order to disseminate
    new knowledge and\
    experience timely and efficiently.

## ^■^ I. HIE Planning: How to Get Started ^■^

Providing practical underpinnings to the construct of health information
exchange requires a complex process that involves developing appropriate
and achievable project goals, devising a shared vision among community
leaders and engaging these constituencies on the road to HIE
construction and implementation. In this session, Michael Heeken
(Florida Governor's Health Information Infrastructure Advisory Board)
provided a look into the planning components of Florida's initiative to
construct a statewide health information infrastructure. Tom Fritz
(Inland Northwest Health Services \[INHS\]) discussed how he was able to
create a sustainable, cost-effective community-wide information exchange
by leveraging assets, creating standardization, and providing
value-added quality services. John Blair (Taconic IPA, Inc.) presented a
case study of the various strategies they employed to overcome the
numerous obstacles they faced when planning for information exchange
among region-wide hospitals and physician practices.

### discussion points

-   Formulating a strategic framework involves forming partnerships with
    all key stakeholders and to actively "market" them to obtain their
    support for an health information network.

-   Realizing tangible results as soon as possible through pilot
    projects that are modest in scope helps manage execution risk and
    allows for forward movement of the project.

-   Community governance organizations require a neutral management
    structure; diverse members have to be willing to work for the common
    good and reach agreements on common issues, e.g. network standards,
    asset sharing, etc.

-   A comprehensive neutral vendor evaluation process is required to
    ensure the selection of a good system and/or agreed upon data set.
    This may include obtaining an independent consultant via a request
    for proposal process; a broad selection committee, which should
    include system users; and data standardization.

-   A sustainable business model is key. Identify the real business
    needs of the participants and their communities, and leverage
    assets.

### key challenges

-   How to create sharing among competitors, e.g. shared standards,
    diverse needs, human resources, vendor selection and management.

-   Providing an efficient cost model, and assuring value-added
    services.

-   Demonstrating value to all stakeholders.

-   Human resources -- need to have in place change management
    expertise; planning, training, implementation, support skills;
    hardware/network support.

-   Vendor interoperability

### key insights/lessons

-   Community governance organizations take work; members have to be
    willing to set aside their self-interests for the common good.

-   Development of standards is important for exchanging information
    outside of the office. Metrics should be developed after standards
    are in place.

-   Financial motivation is a very powerful incentive.

-   Don't try to solve everything; take one issue at a time.

-   Engaging and working with the community can be cost effective and
    beneficial to all; for example, as an important ally with vendors.

## ^■^ II. HIE Organization and Governance Approaches and Models ^■^

Facilitated by Mark Frisse (Vanderbilt Center for Better Health and
Vanderbilt Department of Biomedical Informatics), panelists, Gerry
Hinkley (Davis Wright Tremaine, LLP) and William Bernstein (Manatt,
Phelps & Phillips, LLP), discussed the concept of Regional Health
Information Organizations (RHIOs), in the context of today's emerging
policy issues, business plans, models for advancing health IT/HIE,
financing, formation and governance, and "lessons from the field."

### discussion points

-   Emerging Models for Advancing health IT/HIE include:

-   Grassroots -- No statewide, coordinated effort, driven entirely at
    local level;

-   Convener -- Tasks involve the educator, information clearinghouse,
    and researcher;

-   Catalyst -- Facilitated financing, technical assistance, and project
    development support; and

-   Operator -- Creates the financing vehicle and builds infrastructure
    for information exchange.

-   There are a range of options related to governance structure, tax
    status, terms and conditions of participant agreements, legal
    entity, and liability risks.

-   Key policy issues have yet to be defined with respect to Regional
    Health Information Organizations (RHIOs), for example, the federal
    role, certification/accreditation, state roles, geographic coverage,
    and tax status.

### key challenges

-   The "market" for these efforts is not fully defined.

-   Matching governance principles to organizational options.

-   Determining the pieces of the pie that an organization must own" to
    be viable.

-   Understanding which issues can be addressed locally or which require
    national action

-   Putting into place the right relationships between participants so
    that privacy violations, security breaches, and other threats can be
    managed as efficiently in regional initiatives as they are within
    individual organizations.

### key insights/lessons

-   The term RHIO means different things to different people, and many
    people think that being a RHIO seems to be the politically-correct
    organizational model. However, the government will probably be
    funding a variety of models to see what works and what doesn't.

-   The business planning process of an organization should be
    clinically driven first, followed then by financial and legal
    issues. What makes an organization successful is people coming
    together and wanting the same thing. A strategic business plan will
    drive all future steps.

-   The issue of governance is distinct from the choice of entity,
    although decisions about the former will help guide the latter.

-   Input of stakeholders is essential to the determination of the
    primary goals and purposes of an organization. Understanding
    stakeholder key issues will likely encourage (or discourage) their
    future participation and involvement.

-   One needs to be aware of state privacy laws, which sometimes can be
    a bigger hurdle than HIPAA.

## ^■^ III. Perspectives From The Front Lines ^■^

Panelists in this session discussed actual situations faced in the
implementation of health information exchange including: technical,
legal, and organizational community issues, dealing with technology and
vendors, staff training and data flow. Strategies, solutions and best
practices to address and overcome health information exchange
implementation challenges were discussed. Dr. C. Frederick Lord, (Mt.
Ascutney Hospital, VT) discussed his experiences and lessons learned
with implementing an electronic medical record (HER) into a clinical
environment; Amy Zimmerman (Rhode Island Department of Health) discussed
the approach that Rhode Island State used to design and implement a data
exchange in that state; Michael Matthews (Central Virginia Health
Network) discussed the planning process used to develop a rural e-health
collaborative; and Diane Fields and Margaret Gunter (Lovelace Clinical
Foundation, NM) discussed the political challenges of coordinating and
integrating statewide health IT projects.

### disscussion points

-   Many clinical record systems were outgrowths of financial management
    applications, based on assuming that healthcare work is logical,
    step-wise linear, rationalized, solitary and single minded. However,
    the reality is that clinical work is *not* routine, so implementing
    an EMR record based on financial management applications'
    assumptions will not work.

-   Ways to construct an "electronic health record:"

-   Purchase application from financial management/billing software
    vendor;

-   Replace legacy systems with a single system from one vendor;

-   Leverage existing applications, e.g., select most appropriate
    applications for the purposes required.

-   Success factors in the development of a Master Patient Index (MPI)
    as a core component of an interconnected information system includes
    putting the right information into the hands of the clinicians and
    their patients when and where it is needed.

-   Success can be determined using various measures, including by
    project level, by technology structure (eRX, e-results, e-referrals
    process), or by outcome.

-   New practice options to health IT Adoption:

-   HIE -- view only

-   HIE -- with PM interface

-   Integrated transcriptions

-   Integrated e-Rx

-   Integrated electronic cart

-   HIE feed to other EMR

### key challenges 

-   To identify needs for a system that will be useful, usable and used.

-   Working through state systems.

-   Technical solution needs to meet local needs but be in line with
    national efforts.

-   Managing stakeholder agendas.

-   Identifying management.

-   Sustainability and business models.

-   Legal issues.

-   Engaging physicians.

-   Unique patient identifiers.

-   Building in flexibility to change approach in midstream if
    warranted.

### key insights/lessons

-   It is important to leverage relationships and develop partnerships.

-   Don't automate a system that you already have in place just for the
    sake of automating it. The idea is to make work flow more
    efficiently.

-   An HIE is successful it is useful, usable and used.

-   Stakeholders often want to see immediate results. Consider narrowing
    scope of work, providing less information but demonstrating that
    there is something up, going, and useful -- "Hit the ground
    running."

-   Identify success measures.

-   Leverage technology.

-   Listen -- it is critical to make a compelling business case for
    physicians.

## ^■^ IV. Implementation and Beyond ^■^

This session identified critical sustainability and success factors, the
lessons learned and pitfalls to avoid in health information exchange.
The role and benefits of public/private sector initiatives and issues of
source data, architecture and legal issues were covered, as well. Marc
Overhage (Indiana University/Regenstrief Institute) discussed the top
ten lessons learned and pitfalls to avoid; Mark Frisse (Vanderbilt
Center for Better Health) presented the S.W. Tennessee Project as a case
study in how to build an effective health information infrastructure
across providers and payers; Andrew Chang (Joint Commission on
Accreditation of Healthcare Organizations) examined the value of health
IT relative to an optimal patient safety information system; and, Jan
Root (Utah Health Information Exchange) discussed the UHIN RHIO model of
being the single pipeline to make e-exchange of healthcare data possible
in the State.

###  discussion points

-   Developing a more effective health information infrastructure across
    providers and payers means creating a market, not a product.
    Selection of different architectural models has arisen in different
    areas as a result of need, capability, and circumstances.

-   National and local reporting systems both have advantages and
    disadvantages. One needs to understand both and not supersede either
    one, but rather design the system using a taxonomy that will be able
    to consolidate data from both.

-   What e-exchange is and is not in the context of a RHIO.

### key challenges

-   Defining roles for stakeholders to assure effective operation and
    demonstration of value

-   Picking the model --convener? Financial transaction infrastructure?

-   The clinical data exchange infrastructure? Leave to market?

-   Complete work before the value is "carved" up by disparate
    initiatives

-   Overcoming public perception of loss of privacy/control

-   Building a business case

-   Competing on core services, but not competing on exchange of
    information.

### key insights/lessons

-   There are many ways to achieve some connectivity.

-   Efforts must bring value to all.

-   Trust trumps technology -- one can have the greatest system in the
    world, but if trust is not there, it will not succeed.

-   Governance and compelling value propositions are critical.

-   Take one step at a time -- pick focused, small incremental steps
    that you can back out of.

-   Keep focus on data and not systems.

-   The patient needs to be the focus.

-   Develop and use standards from the beginning; particularly you need
    to have a standardized, unified taxonomy in order to consolidate
    various information systems.

-   Begin with what members think would bring the most value, whether it
    is claim transactions, clinical messaging, baseline software to
    providers, or other.

+----------+-----------------------------------------------------------+
|          | # C. ASSESSING VALUE AND EVALUATING HEALTH IT             |
+----------+-----------------------------------------------------------+

Blackford Middleton and Marc Overhage oversaw this track, which was
conducted over Thursday, June 9^th^ and Friday, June 10^th^. Sessions in
this track focused on study design and methods for evaluation,
culminating with a presentation of case studies and open forum
discussion.

High level insights and findings from this track include the following:

-   When designing a study, it is important to understand the
    interventions, define the measures, and understand what you are
    capable of as an organization when defining the evaluation design.

-   It's a practical world -- operational issues get in the way, and you
    need to be prepared for that

-   Avoid too frequent measurements, but intermediate time points can
    add crucial information about the impact of intervention over time

-   Know your hypotheses -- not all surveys will be relevant to testing
    the hypothesis

-   Instrument selection is very important.. Be sure that the instrument
    is appropriate for your population and has been validated

-   It's hard to evaluate implementation processes systematically, but
    AHRQ is very interested even in non-systematic information grantees
    can provide through their implementations and the lessons to be
    learned therein because they may help us to draw broad conclusions.
    Provide these in quarterly and annual reports, even in appendices.

-   There are big differences between partial involvement vs. mandated
    involvement vs. mixed model.

-   If you think your evaluation shows some improvement, do qualitative
    analysis to figure out why.

## ^■^ I. Basic Study Design and Quantitative Methods ^■^

This session focused on study design, providing an overview of why
evaluation is important and an overview of various study approaches.
Eric Poon (Partners Healthcare) talked about the methods for study
design and evaluation and David Lobach (Duke University Medical Center)
discussed an application of the study methods at Duke, providing an
insight into evaluation in the "real world".

### discussion points

-   Why evaluate healthcare IT?

-   Impact of health IT is often hard to predict

-   Understand how to clear barriers to effective implementation

-   Many ways for health IT to fail -- so need lessons that can be
    applied broadly so that there is no need to reinvent the wheel

-   Need to justify the enormous investments made into health IT --
    politicians are focused on outcomes

-   Use results and data to win over late adopters

-   To continuously improve health IT you cannot manage what you cannot
    measure

-   General approach to health IT study design

-   Understand your intervention

-   Formulate questions

-   Select and define measures

-   Pick the study design

-   Avoid common pitfalls with data collection

-   Cost-benefit analysis: Do the benefits of the technology justify the
    costs? Cost analysis is more straightforward; Benefits analysis is
    more controversial.

-   Example of showing health IT Value: evaluate the value of health IT
    from different perspectives (clinical, financial, organizational,
    societal)

### key challenges

-   Controlling expectations: people want to know, get excited

-   Avoiding "Scope creep"

-   Adjust for multiple measures

-   Start up funding, operational funding

-   Obtaining data from partners

-   HIPAA implications

-   Challenges working in the community setting

-   How to navigate academic institutions -- IRB approval for health IT
    projects can be problematic (not getting consent for usual standard
    of care can take a year! The IRB might try to make your project fit
    their paradigm.)

### key insights/lessons

-   Understand what you are capable of as an organization when defining
    your evaluation design.

-   It's a practical world -- operational issues get in the way, and you
    need to be prepared for that.

-   Life (data collection) is like a box of chocolates...you don't know
    what you will get until you look, so look early! Look for surprises.

-   How to work with your community partners -- need to establish trust,
    focus on learning from them instead of them learning from you.

## ^■^ II. Survey and QUalitative Methods for Evaluation ^■^

This presenters in this session discussed methods for survey and
qualitative methods for evaluation. Adil Moiddudin (NORC/AHRQ NRC)
provided an overview of survey design methodologies and qualitative
methods followed by Lee Goldberg (University of Pennsylvania) who
provided an overview of his study comparing 3 different care models for
outpatient heart failure care. Finally, Ken McConnochie (University of
Rochester/Strong Children's Research Center) discussed using an economic
model of organizational architecture to guide design and evaluation of
an urban, primary care telemedicine network.

### discussion points

-   Sampling methodology: define your population, randomly select your
    participants, stratification and over sampling, target response rate
    for a statistically meaningful result.

-   Tips on increasing response rates: Personalize initial approach; Use
    the Dillman approach; Questionnaire format; Optimize follow-up for
    your budget.

-   Evaluating health IT is a SOCIAL science -- you're evaluating how
    people use technology and the relationship between how they use
    health IT and the outcomes you're interested in.

-   Start with defining the question: What question do you want to
    answer? May depend on the asker -- partners on your project may not
    agree on what question! Is your question disease-state specific or
    general quality of life? Is the survey measurement a primary or
    secondary end-point of your study? This will matter statistically.
    What changes do you expect -- what is the magnitude of the change?

### key challenges

-   Qualitative methods offer highly valid results through an in-depth
    understanding of processes, attitudes, effects. Don't count on
    getting the same result during a second data collection because you
    will talk to different people.

-   Stakeholders' perspectives don't always align, even between patients
    and providers. For example, health IT can be a burden on physicians.
    How to weight these different perspectives?

-   Cannot use all instruments for evaluation.

-   Pre-existing instruments are rare for health IT. Are there validated
    instruments? How to validate a newly-created instrument?

### key insights/lessons

-   Avoid too frequent measurements, but intermediate time points can
    add crucial information about the impact of intervention over time.

-   Pilot test!! Very important. Can do cognitive testing on people
    similar to target population.

-   Know your hypotheses! Not all surveys will be relevant to testing
    the hypothesis.

-   Instrument selection is very important.

-   Be sure that the instrument is appropriate for your population and
    has been validated.

-   Incorporate the instrument into your protocol and into the planned
    statistical analysis -- make sure that everyone can understand what
    data you will get back and when it will be complete.

-   Selecting the appropriate survey requires clear understanding of the
    project and anticipated outcome. Involve all team members and get
    their buy-in.

## ^■^ III. Health It Evaluation Case Studies ^■^

Jack Starmer from Vanderbilt University Medical center moderated this
session featuring grantees providing case studies of their evaluation
efforts on their projects. Sue Kraus (CCHS-East Huron Hospital)
discussed how workflow redesign was a key challenge in implementing an
EMR, followed by Pascale Carayon (University of Wisconsin-Madison)
discussed evaluating CPOE implementation in ICUs. Karen Fox (TECH-Net)
provided an overview of a multi-state network to implement a systemic
care program to improve cancer management in Tennessee, Northern
Arkansas, and Eastern Mississippi. Beth Devine (University of
Washington, Everett Clinic) described evaluation of prescribing errors
pre and post-CPOE in the ambulatory setting.

### discussion points

-   EMR Process Redesign Efforts - CCHS

-   Assembled expert workgroups 6 to 9 months prior to implementation to
    document workflow in each area, gave them training, and started
    conversations on how workflows would change.

-   Physicians have to want to use the system and have a voice in
    designing the system; May need to hire expert physician consultants
    to staff physician advisory committees.

-   Nursing units participated in unit-specific redesign process prior
    to "going live" to allow for front-line feedback and training.

-   Goal was to measure the following:

-   1 -- Quality of Care Measures -- process and quality

-   2 -- End user impact of technology on tasks and jobs; Measured by
    job task analysis by function and survey of end users before and
    after CPOE

-   3 -- Financial Value measured by Hospital-based accounting system

-   4 -- Prospective Human Factors Analysis: heuristic inspection of
    user interface, scenario-based user testing (efficiencies,
    misunderstandings, errors made to provide feedback), prospective
    risk analysis (FMEA, RCA, etc.), human factors technology design and
    implementation

-   Effectiveness of product: were patients given evidence-based care,
    use of accepted protocols, rate of treatment success

-   Efficiency: opportunity loss of physician travel, patient travel

-   Equitable: quality of care provided to rural vs. urban patients,
    proportion of patients in clinical trials

-   Not just before and after results -- the technology itself evolves
    and changes depending on results. It's not a one-shot deal for
    training on using the system.

-   Incremental implementation of a system to allow for fixing errors on
    an ongoing basis.

### 

### key challenges

-   CCHS -- Focus on efficiency: workflow redesign was one of the
    greatest challenges, more than the technical implementation aspects.

-   Long distances between facilities make it very difficult to
    implement and analyze systems.

-   TECH-Net encountered obstacles in physician and staff turnover due
    to Medicare oncologist reimbursement rate changes, challenges in
    acceptance by physicians and staff, and unexpected issues with
    wiring.

-   Must deal with the intersection of ideal and practical -- there is
    no magic answer for finding the perfect answer for this dilemma!

### key insights/lessons

-   Standardization of ordersets according to best practices -- moved
    from 4 formularies to one at CCHS.

-   Understand the implications of the lack of an integrated pharmacy
    module which is key to the adoption of CPOE.

-   Combining telemedicine with EHR: Measuring both costs of patients
    and physicians is very important.

-   Patients no longer need to leave work for extended periods to go to
    clinics.

-   TECH-Net: Preliminary data suggest 47% patients like the telemed
    care better -- the physician spends more time looking at the
    patient, not looking for chart or leaving room, showing more
    attention to the patient (though actually the physicians spent less
    time with the telemed patients).

-   Everett Clinic: Dramatic decline in each category of error post
    implementation. Characteristics of errors: missing information was
    most frequent error, illegibility was third on the list. Lab
    monitoring errors were some of most severe. Few drug-drug or allergy
    interactions.

-   Need to take into account cultural preparation -- especially, lead
    from the top!

-   There are big differences between partial involvement vs. mandated
    involvement vs. mixed model.

-   If you think your evaluation shows some improvement, do qualitative
    analysis to figure out why.

## ^■^ IV. Open Forum With Health IT Evaluation Experts ^■^

There was no set agenda or prepared comments from panelists in this
session -- it was geared for the audience to ask questions and generate
lively conversations. Blackford Middleton and Carol Cain moderated this
session with John White (AHRQ), Ross Koppel (University of
Pennsylvania), and Eric Poon (Brigham and Women's, Partners) serving as
panelists.

### discussion points

-   Implementation is a constant, evolving process

-   Evaluation plans are driven by theory

-   Grantee stories should be disseminated to the general medical
    community

-   Involvement of outside stakeholders

-   Reporting of failures can be as insightful as reporting of successes

### key challenges

-   Grantees may be evaluation novices

-   Appropriate involvement of other stakeholders can be a challenge

-   Lack of standardization of applications and measures

### key insights/lessons

-   Training and systematic recording is critical on all levels.

-   A standardized measure is more useful than a standardized
    application.

-   Evaluations should consider how technology is impacting the workload
    of front-line staff.

-   Evaluation is an ongoing process.

+----------+-----------------------------------------------------------+
|          | # D. PUBLIC TRUST IN HEALTH INFORMATI                     |
|          | ON SYSTEMS: HANDLING PRIVACY, SECURITY AND RELATED ISSUES |
+----------+-----------------------------------------------------------+

John Halmaka, of Harvard Medical School/CareGroup Health System, and
Susan Christensen, of AHRQ, oversaw this track, which dealt with the
issue of privacy, which is often identified as one of the foremost
challenges in achieving public confidence and widespread
interoperability of electronic health information system. The track's
expert speakers addressed a wide variety of electronic systems privacy
topics, including baseline HIPAA privacy and security information,
practical challenges with HIPAA compliance, how to build a culture of
confidentiality beyond HIPAA requirements, and the consumer component --
fears, desires, and what is needed for trust in electronic information
exchange.

High level insights and findings from this track include the following:

-   States may have more stringent electronic privacy rules than HIPAA.
    It is important to be aware of both federal and state legislation.

-   When using data for research purposes it is important to ensure that
    data is de-identified to the extent required by HIPAA and IRBs.

-   Privacy spills from inside authorized users are more prevalent than
    those caused by external hackers. "Think like a crook" to identify
    risks and set up procedures to deal with these risks.

-   It is important to communicate privacy practices and policies to the
    local community to enhance public confidence in electronic systems.

-   Be consistent in enforcing sanctions for systems breaches. Universal
    and transparent policy is important to building public trust.

-   Comprehensive security policy compliments technical security
    infrastructure. Both are critical to an effective system.

-   Audit logs are an important monitoring tool to ensure that security
    policies are enforced. These logs do not take excessive amounts of
    disk storage or slow down production systems.

-   Carefully consider security implications of adding new products or
    technologies to the enterprise. Unforeseen effects can result from
    lack of careful planning.

-   Data interchange among organizations requires a distributed security
    model in which organizations each take responsibility for
    authenticating and authorizing their respective users. Trust is
    essential to this.

## ^■^ I. HIPAA 101: Basic HIPAA Privacy and Security ^■^

This session was designed to provide a basic overview of HIPAA privacy
and security requirements including what they are, how they work, and
how to successfully apply them. Sue McAndrew of the HHS Office of Civil
Rights provided an overview of the HIPAA legislation and detailed
specifics of the privacy rule including covered entities, permitted
disclosures, and compliance. Next, Stanley Nachimson of CMS overviewed
the requirements and regulations set forth in the security rule and
offered advice for the successful implementation of organizational
security standards.

### discussion points

● Basic HIPAA Privacy and Security.

○ What is the legislative history of HIPAA and who is responsible for
legislative oversight?

○ Who is covered by HIPAA?

○ What is the privacy rule? What are permitted disclosures?

○ Who oversees compliance? What happens with complaints?

● HIPAA Security Standards

○ What are general requirements of security rule and major themes of
regulation?

○ What are HIPAA security safeguard standards?

○ How do you implement an effective system of security policies and
procedures?

### key challenges 

-   State laws may be more stringent than the HIPAA federal floor.
    Covered entities must be aware both of HIPAA and state policy.

-   Determining who are covered entities (e.g., business associates,
    etc.) can sometimes be a difficult task.

-   HIPAA privacy rule is subject to voluntary compliance. Complaints
    are investigated by OCR and the main goal is to bring providers to
    comply voluntarily, but monetary and/or criminal penalties can be
    imposed where appropriate.

-   Entities must develop security policies that balance protecting
    information with appropriate practical use.

-   Security standards must be reevaluated based on periodic
    organizational assessment of risks.

### key insights/lessons

-   HIPAA covered entities include all healthcare providers who transmit
    individually-identifiable health information electronically.
    Business associates are agents or contractors hired to do business
    for the covered entity that requires use of protected health
    information. BAs are not covered entities, but are subject to
    contractual agreements with covered entity that regulate use of
    protected information.

-   HIPAA is the federal floor. States may have more stringent privacy
    regulations.

-   Security measures were set up to ensure that privacy rules were
    complied with. HIPAA covers all protected information an entity
    creates, receives, maintains or transmits.

-   Regulation requires that entities protect against reasonably
    anticipated threats or hazards to security, integrity, or
    inappropriate disclosure of information. Regulations set up to be
    scalable, flexible, technologically neutral and comprehensive in
    nature.

-   There are 6 sets of standards: general rules, administrative
    safeguards, physical safeguards, technical safeguards,
    organizational requirements, documentation requirements, and
    policies and procedures.

-   To implement security standards first do a risk analysis, based on
    this look at each standard and implementation specification, develop
    security policies and procedures, implement policies and procedures,
    train workforce, and conduct periodic evaluation and modify where
    necessary. Make sure to document each step of the process.

## ^■^ II. Privacy and Security: Practical Consideratons ^■^

This session featured a panel discussion on practical issues related to
privacy and security, including legal issues related to PHI, how HIPAA
regulations affect research, and an overview of potential
technological/software risks. The session also presented case studies
detailing how two programs implemented successful security policies and
mediated security concerns of their IRBs. Rebecca Williams, a lawyer who
advises clients on their security programs, discussed how to develop
policies that meet legal requirements. Lora Kutkat of the NIH outlined
the implications for HIPAA on health services research. Robert Williams
overviewed technical issues related to technology and software and
Sanjeev Arora and Gail Bellamy discussed security issues related to
their individual projects, a rural telemedicine disease management
system for Hepatitis C and a hospital-based quality improvement project,
respectively.

### discussion points

-   Legal Issues Related to Community Health Information Exchange

    ○ What are the different community-collaboration structures and how
    do they impact PHI security policies?

    ○ How do you universalize individuals rights across PHI
    collaborators and what are necessary policies in government
    collaborative information exchange?

-   Impact of HIPAA on Health Services Research

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-   How is health services research distinct and how is it affected by
    the privacy rule?

-   When is authorization required and what are IRB/Privacy Board
    criteria for waiving/altering authorization?

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-   Practical Security and Software Challenges

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-   What are common technical and software security challenges and how
    can you protect yourself from potential threats?

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-   Security issues of implementing a telemedicine disease management
    system

    ○ How do you ensure that staff receive only appropriate levels of
    access to patient data?

### key challenges

-   Being aware of constantly changing security environment, including
    changing laws, unforeseen obstacles, and interactions with players
    involved in PHI exchange. Need to make sure that organization
    continues to meet legal requirements in changing environment.

-   Community-collaboratives (including RHIOs) can sometimes span across
    several states. Need to be aware of and accommodate legal
    requirements of all locales.

-   Awareness of how privacy rule effects individual research and how to
    utilize appropriate channels to obtain authorization where required.
    Research presents unique challenges because data are often obtained
    through covered entities, but without organizational contact with
    subjects or IRBs.

-   Developing a comprehensive security policy that recognizes and
    addresses the wide array of potential security threats.

### key insights/lessons

-   Take a periodic pulse and evaluate your program and changing
    interactions within PHI collaborators. Determine who controls PHI,
    who has access to PHI and what appropriate roles are with regards to
    patient information.

-   The privacy rule permits covered entities to release information for
    research with individual authorization or without authorization when
    data is completely de-identified. Limited data sets, which include
    limited identifiers, can be released but only when use is specified
    through data use agreement between covered entity and recipient.

-   Policies, behavior and technology all affect program security.
    Comprehensive security policy must address all three issues. It is
    important to understand the security implications of any new
    software you bring into your system.

-   Policies should be set up to ensure that staff at different levels
    receive only minimum patient information required to complete their
    respective jobs.

-   Quality improvement studies can be an important way to improve
    patient safety and hospital performance, but need to ensure
    confidentiality and gain confidence of participants to make them
    comfortable sharing potentially sensitive information.

## ^■^ III. Building a Culture of Confidentiality and Securtiy ^■^

Presenters in this panel discussed the policy and technical issues
common to privacy and security strategy and implementation. Focus was
placed on how to ensure trust through transparent and universal
governance models, including key stakeholders in policy implementation
and formulation, communicating privacy and security policies to multiple
community audiences and addressing potential breeches and complaints.
John Halmaka relayed the policy challenges faced by his organization,
CareGroup Health System and RHIO. Holt Anderson of North Carolina Health
Care Information and Communications Alliance, Inc. discussed the major
problems and issues faced by collaborations sharing electronic patient
information. Soumitra Sengupta of New York-Presbyterian Hospital
outlined the use of audit trails to ensure security policies are
complied with. Gary Cristoff of National Institutes of Health iterated
the importance of trust, and how to achieve it, in an increasingly
complex and interconnected environment. Finally, Kathleen McCormick of
SAIC Health Solutions discussed the theoretical linkages between
dependency and risk, and how to create a dependable system that creates
the least risk possible.

###  discussion points

-   How to control information access in a large organization.

-   How to build policies that encourage public trust in EHR systems.

-   What are different community-collaborative structures and what are
    unique security issues faced by each?

-   How to ensure that policies on information sharing and technology
    remain transparent and concrete across different organizations
    involved in information sharing.

-   What is an audit trail and how can an organization use it to ensure
    security policies are adhered to?

-   Designing policies that build public trust in health information
    technology.

-   What can we do to build a culture of public trust in health IT?

-   What is the relationship between dependency and risk?

-   How can we minimize risk within organizational structures?

-   What are guidelines for creating dependable structures?

### key challenges

-   Making sure that organization employees receive access to minimum
    necessary information and that violators of policy are dealt with in
    a way that encourages trust.

-   Coordinating policies and practices across organizations in
    connected healthcare communities.

-   Ensuring that security policies are adhered to by organization
    staff.

-   Encouraging public trust in healthcare technology.

### key insights/lessons

-   Access control should be utilized based on individual's role in the
    organization. Education of staff is crucial to effective policy.
    Violators of policies should be dealt with uniformly and
    transparently to encourage public trust, and efforts should be made
    to increase public knowledge of security policies and practices.

-   Complexity increases as more organizations are involved in
    information sharing. Potential difficulties include the anticipated
    and the unanticipated.

-   Audit trails are an effective means of security control, but require
    consolidation, intelligence and procedural investigations to make
    them useful. Communication and education of staff about audit logs
    and permissible access are also crucial to successful policy.

-   As dependency on technology increases, so do the potential risks.

## ^■^ IV. Consumer Perspectives ^■^

Instilling patient confidence in electronic medical records is one of
the most crucial, and most difficult, components of creating a
successful electronic health information system. This panel outlined
various issues related building consumer trust in electronic information
exchange including how and when to get consumers involved in planning
and implementation, the current state of public attitudes towards EHR,
and ideas for raising public awareness, and addressing public concerns,
about electronic patient information. Alan Westin, of the Opinion
Research Corporation, discussed current public perceptions of EHR based
on recent survey data. Beth Darnley and Aaron Marshall, of the Patient
Advocate Foundation, outlined the important role patient-advocacy groups
can play in bridging the gap between patients and policymakers in the
health IT debate. Peggy Frank described her personal experiences with
health IT and described public relations techniques for emphasizing
human aspects of health IT and benefits to consumers. Finally, David
Lansky of the Markle Foundation relayed the important of designing
consumer-driven policies and offered advice for how to effectively bring
consumers into the policy process.

###  discussion points

-   What is the current state of public knowledge about electronic
    health information and what are the public's main concerns?

-   How can patient advocacy groups and other non-profits benefit health
    IT development?

-   What are good techniques for diffusing information and trust in
    patient populations?

-   What are effective strategies PR strategies for selling health IT to
    the public?

-   How do we design policy geared towards public concerns?

### key challenges

-   Keeping abreast of changing public opinions and concerns about
    electronic health information and incorporating these concerns into
    internal organizational policies.

-   Involving the public in development and implementation of health IT
    policies.

-   Emphasizing the human aspect of health IT and relaying to consumers
    why it is important to them.

### key insights/lessons

-   Patient empowerment and participation, as well as continued
    monitoring of public perceptions, are critical to effective adoption
    of electronic health technology.

-   Patient advocacy groups and other nonprofits can be important
    resources in bridging the gap between patients and policymakers.

-   The public needs to be shown the human face of health IT and
    emphasis needs to be placed on why it is important to them.

-   Information diffusion needs to be targeted to meet public interests
    and concerns. Policy should be transparent and emphasize security.

+----------+-----------------------------------------------------------+
|          | # E. COORDINATING CARE USING IT AND TELEHEALTH            |
+----------+-----------------------------------------------------------+

Mary Wakefield, of the University of North Dakota and Julie McGowan, of
Indiana University School of Medicine, led this track, which explored
how information technology can be used to coordinate care across various
settings. In an increasingly complex and distributed healthcare
environment, technology, if used properly, can make this environment
more provider-friendly and patient-centric. The track included
discussions on the use of technology in various settings including
pediatrics, e-prescribing, telehealth and communication across
providers. The roles of such technologies, and impacts in various
settings were examined.

High level insights and findings from the track include the following:

-   Distributed healthcare, particularly in rural communities, offers
    unique challenges to implementing health IT. Being rural and
    successful requires a vision, money, and a few key leaders.

-   One health IT solution is not right for everyone. It is important to
    think globally but act locally; however, it is unclear as to how
    local success scales to a national plan.

-   Garnering early buy-in and understanding of the implications of
    health IT adopting from primary and secondary beneficiaries of
    health IT systems needs to be considered as important as the
    selection of the best technology.

-   The cultural issues involved, especially in dealing with health IT
    empowerment, can be substantive.

## ^■^ I. Health IT and Pediatrics ^■^

Case study presentations featured in this session addressed the role of
health IT in pediatrics, detailing specific scenarios including an
electronic health profile for children with special needs, electronic
data capture and knowledge management in a children's hospital, and
electronic records designed to improve care for pediatric asthma
patients. Carmen Lozzario provided an overview of the University of
Tennessee's program which is working to set up an electronic health
profile for children with special needs. Stephen Porter from the
Children's Hospital in Boston, discussed a unique initiative through
which parents enter data on their child's asthma history. Finally,
Richard Shiffman of the Yale Center for Medical Informatics, spoke about
the use of health IT to improve care for childhood asthma.

### discussion points

-   Electronic health profile for children with special needs

-   Patient-centered health IT in Pediatrics

-   Improving pediatric asthma care through health IT

-   How can we utilize and implement best practices through technology?

-   What are the benefits of improved information sharing across
    providers?

### key challenges

-   Data from different sources can sometimes be difficult to match,
    especially for children. Watch for different spellings of names and
    incorrect SSNs.

-   Securing access to data across providers, designating how and where
    data will be stored, and ensuring data is only used for designated
    reasons.

-   Information entered by patient must be checked and validated to make
    sure it is correct. While pictures can be helpful to identify
    current medications, they can sometimes be misleading due to
    different medicinal packaging.

-   It is often difficult to get physicians to use new technologies
    because it breaks away from their established norms of practice.
    Effort must be directed towards resident education in new health IT
    systems.

### key insights/lessons

-   Electronically linked databases can offer important benefits to
    pediatric care, including improving health care delivery, providing
    single-service secure website access, providing comprehensive
    medical data to physicians, reducing redundancies and medical
    errors, allowing for long-term tracking, and avoiding "lost cases."

-   Patient-centered care allows customization of treatment based on
    individual patient needs, but requires free-flow of information
    between patient and providers to be effective. Safety must always be
    a system priority.

-   Patient reporting, through computer centers, can collect information
    on current illness state and history, current medications, reactions
    to previous medications, current DM practice and unmet needs. This
    information can then be utilized by the provider to improve patient
    care.

-   Patient-entered information on current medication is often more
    valid than nurse or physician entered information due to patient's
    familiarity and expertise in their own care.

-   Knowledge-based clinical decision support systems (CDSS) can help
    improve patient care by reducing communication errors and improving
    treatment effectiveness through clinical decision support.

## ^■^ II. Case Studies: Adoption of e-Prescribing ^■^

This session presented an overview of e-prescribing, the infrastructure
needed to support it, key benefits of implementation and proven
strategies for overcoming implementation hurdles. Rural electronic
medication initiatives were a particular focus. Jean Tichy of WI's
Marshfield Clinic, discussed the planning and implementation of an
electronic rural prescription partnership, which will make real-time,
accurate prescription data available for patients seeking care at any
participating clinic. Joel Weissman of the MGH/Harvard Institute for
Health Policy overviewed the Massachusetts eRx collaborative, which has
sought to measure the impact of eRx on patient safety, as well as cost,
utilization and outcomes. Finally, Paul Gorman of the Oregon Health and
Science University overviewed the RxSafe program which is using IT to
facilitate medication reconciliation and communication between nursing
homes, medical providers and pharmacies.

### discussion points

-   Designing a network that merges an electronic master patient index,
    a master medication list, and an inventory of allergy and adverse
    reactions across providers to improve patient safety.

-   Overview of current attempts to evaluate a voluntary e-prescribing
    collaborative in MA. The study is testing the efficacy and cost
    differences between adopters of e-prescribing and non-adopters to
    gain a better sense of the implications of such initiatives on
    patient safety and medical costs.

-   IT can be an important tool to improve patient safety and care
    through better communication that replaces fax machines and written
    reports, which are prone to human error and communication
    inefficiencies.

### key challenges

-   In their developmental stages, electronic systems may require a
    significant amount of manual effort to be effective. It may also be
    difficult to exchange information across different interfaces,
    especially demographic information which may be collected
    differently at different sites.

-   In a rural setting, electronic prescription networks may be
    complicated by the fact that smaller clinics may not have EHR.
    However may of them will have e-prescribing, and thus still be able
    to be integrated into the larger network.

-   E-prescribing costs for an individual prescriber are estimated
    anywhere between \$1,600 to \$10,000 for the first year and
    \$950-\$2,800 for subsequent years. Adequate first year funding is
    critical is critical to successful implementation.

-   In a nursing setting prescription monitoring is especially
    problematic because it involves multiple complex patients and
    sharing of information across different shifts and providers.

-   Use of fax machines to communicate between different providers is
    especially problematic.

-   Creating a system that meets the disparate goals and needs of
    different organizations (for example nursing homes, providers and
    pharmacies) can be a difficult process.

### key insights/lessons

-   If designed in a way that is easy to use and access, prescription
    networks can be an effective way to increase patient safety.
    Consistent evaluation of the system and enhancement to meet
    community needs and concerns is crucial to system efficacy.

-   The MMA requires new prescription drug plans to use e-prescribing
    by 2006. The emergence of low-cost technologies and palm-size
    devices has made this move a reality and it will have important
    implications for patient safety.

-   E-prescribing has several functional advantages. It increases the
    ability of the prescriber to write prescriptions on the fly, it lets
    the provider and patient know what is on the patient's formulary and
    what the associated co-pay costs may be, and it alerts to
    potentially harmful drug-drug interactions and can potentially
    incorporate the patient's medication history.

-   Current studies are examining data to see if error rates improve
    among e-prescribing adopters and whether there are cost-advantages
    to patients through increased use of formularies and generics and
    decreased ED visits and hospitalizations for patients with chronic
    conditions. The results of these studies through the MA
    E-prescribing collaborative are forthcoming.

-   E-prescriptions can help create a seamless system between nursing
    homes, providers and pharmacies that gets rid of the human error and
    inefficiencies associated with fax and paper communication between
    entities.

## ^■^ III. Changing Clinical Practice for Telehealth ^■^

This session featured a number of case presentations focusing on how to
build, monitor and sustain telehealth initiatives. The issues of
integration, interoperability and sharing records in rural settings were
specific issues of focus. Beth Evermon discussed the use of health IT to
improve patient access to care in rural areas. Dennis McColm discussed
the issues of integration and interoperability of systems faced by
Citizen's Memorial Healthcare in implementation of their health IT
system. Jane Brokel of Trinity Health discussed the re-design of care
through EHR in her rural Iowa community. Finally Jami Young and Michael
Rodriguez, standing in for Kiki Nocella of USC Keck School of Medicine,
discussed health IT strategies for rural health care institutions.

### discussion points

-   How can health technology be harnessed to improve patient care?

-   What are the issues faced in attempting to integrate various
    locales' EMRs?

-   What are benefits of shared EMR and why are they important?

-   How can shared EHR utilize clinical practice guidelines?

-   What are major challenges to implementing shared EHR and how can
    they be dealt with?

-   What are major difficulties for implementing a rural telehealth
    program?

-   How can we get various stakeholders in the community involved in and
    trusting the process?

### key challenges

-   Benchmarking, interoperability of disparate systems, and creating a
    shared understanding of visions and goals across providers are key
    challenges in health IT adoption.

-   Shared Ambulatory Medical Records offer vast potential to rural
    service areas, but are difficult to implement.

-   For integration of EMRs to be successful there must be strong
    consensus across providers and universal recognition of
    shared-system's value.

-   There is a huge wealth of data on clinical practice. Need to find a
    way to package this back to the physician in a usable format.

-   Creating a uniform language across technologies is a tricky process
    and one that needs to be routinely checked and modified to ensure
    proper system operation.

-   Integrating systems between departments (especially medical and
    accounting) and disciplines can sometimes be difficult due to
    different terminology.

-   Building physician trust in telehealth systems can be long and
    sometimes painful process.

### key insights/lessons

-   Health IT can aid access in rural service areas by allowing for
    computerized provider order entry, electronic signatures, medication
    administration records, community-wide scheduling, improved home
    health and hospice care, PACs and remote access for providers.

-   Shared-EMR can improve patient care by creating a personal identity
    for each patient within a community-wide continuum of care and by
    allowing physicians access to patient information across the
    continuum to improve treatment.

-   Acquisition guidelines for providers wishing to join systems are a
    common systems solution that can help ensure integration and
    interoperability of systems.

-   Trust is one of the most important factors slowing implementation of
    telehealth systems.

## ^■^ IV. Managing Clinical Handoffs Across IT Settings ^■^

This interactive panel presentation examined technologies that
coordinate care across care settings, highlighting issues such as
participation among providers, specialized safety-net strategies and
infrastructure and interoperability concerns. Carol Ireson discussed the
University of Kentucky Medical Center's use of electronic referrals.
Bruce Ferguson overviewed LSU's efforts to combat cardiovascular care
disparities through safety-net health IT. Daniel Venecek and Wendy
D'Angelo talked about Concord Hospital's decade long experience with EMR
and integration. Gail Keenan and Elizabeth Yakel discussed health IT
support for safe nursing care at the University of Michigan. Finally,
Jerry Gurwitz discussed patient safety in the nursing home setting.

### discussion points

-   Improving coordination and effectiveness of referrals between
    primary and specialty care

-   Utilizing health IT to improve health disparities in cardiovascular
    disease among uninsured populations

-   Connecting providers through EHR

-   Implementing health IT to support nurses in a dynamic Care Planning
    Process (CPP)

-   Improving safety with anticoagulation in the nursing home setting

### key challenges

-   Some physicians resist moving towards electronic referrals. (Be
    aware of who these physicians are and avoid them.)

-   Providing the "right" information to the "right" people at the
    "right" time can sometimes be a difficult task.

-   Even with advanced technology, transitions between the outpatient
    and inpatient settings are difficult. Medicines are the most
    difficult and have the potential for the most error. Safety
    precautions need to be taken.

-   Providers are quick to reject any new procedures or technologies
    that increase their workload.

-   Implementing a successful CPP nursing system requires a change in
    culture in the way nurses communicate with one another.

### key insights/lessons

-   Utilize physicians in designing and implementing templates for EMR,
    electronic referrals, etc.

-   Electronic referrals can improve medical care by decreasing
    miscommunication between providers, increasing efficiency and
    effectiveness of care by increasing patient and physician
    satisfaction and reducing redundancy in tests and procedures.

-   Success in shared systems depends on success in sustained
    partnerships.

-   Even with the most advanced technology, no EHR system is perfect.
    You need strong leadership and communication to recognize challenges
    and set up systems to correct them.

+----------+-----------------------------------------------------------+
|          | #                                                         |
|          |  F. HEALTH IT NUTS & BOLTS: TACKLING THE TECHNICAL ISSUES |
+----------+-----------------------------------------------------------+

National Resource Center Deputy Project Director and Health Information
Technology implementation expert Joy Keeler and Partners Healthcare Vice
President and CIO John Glaser oversaw this track, which included five
sessions over the final two days of the Annual Conference. The sessions
focused on real-world details of health IT such as data standards,
buy-in, finance, and provider training models. The track addressed a
variety of topics including organizational redesign, inter-institutional
data sharing and standards, legal implications of data sharing, and
effective training and adoption strategies. Sessions further examined
barriers to successful adoption and integration, along with presenters'
experiences with successful strategies for overcoming them.

High level insights and findings from this track include the following:

-   Implementing health IT is not a traditional IT project and requires
    special consideration. Implementing health IT systems will
    fundamentally alter the way a practice operates and does business
    every day, and the process will expose other hidden problems. It is
    necessary to be prepared for all this.

-   Effective, ongoing training is critical to a successful health IT
    implementation.

-   Strong, widely-accepted data standards are critical to the success
    of health IT on a national scale. Standards only work if everyone
    can use them -- interoperability is key.

-   Standards are not advancing at a rate sufficient to keep abreast of
    policy or technology. Regionally successful standards may not work
    as national standards, as the scale is much different.

-   Patient identification is a crucial piece of the puzzle, and there
    are good and bad ways to accomplish it. There are significant legal
    considerations for this kind of data, and institutions must clearly
    define policies to protect information.

-   Clinician adoption continues to be a major challenge in the
    deployment of EHRs.

-   Patient readiness for access to their clinical information is ahead
    of clinician readiness to share.

-   Proliferation of new technologies represents security and investment
    challenges for health care.

## ^■^ I. Organization Redesign and Clincial Change ^■^

Two AHRQ grantees described strategies and processes they found
successful in effecting organizational and clinical change while
implementing health IT solutions in two regional systems. Greg Kall
(Cleveland Clinic Health System) walked through the implementation of an
in-patient CPOE system, highlighting the differences between traditional
IT and health IT implementation projects, and James Ralston (Group
Health Cooperative) described the effects of a health IT implementation
on long-term (5 years) organizational redesign within a member-governed,
not-for-profit integrated financing and care delivery system.

### discussion points

-   The technology is the easy part -- there is no roadmap to
    implementing it.

-   Act quickly as organizational commitment appears to be declining.

-   Start a search and selection team that includes doctors, nurses,
    ancillaries, IT and finance staff.

-   Define what you want from the system -- interfaces should follow the
    clinical workflow. Making forms similar to paper versions helps get
    providers on board.

-   The implementation team should include members from all areas of the
    organization, especially physicians and nurses. This is necessary to
    achieve buy-in from all groups.

-   Patients are very interested in health IT, but access must be
    simple. When registration for patient portal access was made easier,
    many more patients signed up.

-   Patients are less interested in seeing providers' notes online than
    they are in asking simple questions, getting prescription refills,
    seeing lab results, etc.

### key challenges

-   Application of technology into the clinical workflow

-   Provider buy-in

-   Training users and keeping them up-to-date

-   Pharmacy integration is difficult but crucial

-   Managing expectations

### key insights/lessons

-   It is critical that you do not underestimate the amount of training
    required of nursing, medical, and all other staff.

-   From the beginning, you must manage expectations: this kind of
    project will take years.

-   All parties in your institutions, especially providers, must be and
    feel involved from the start.

-   Integration of pharmacy systems into the pharmacy workflow is
    critical -- providers' ordering and pharmacists' languages must be
    the same

-   The implementation team must include a large number of non-IT staff.

-   Need to have a strong leader as a physician "champion" for the
    project.

-   It is critical that the system is integrated into all aspects of the
    workflow.

**^■^ II. Inter-institutional Data Sharing, Standards, and Legal
Implications ^■^**

Two AHRQ health IT grantees and two national experts shared their
thoughts and experiences on the evolution and use of data standards for
information sharing. Ed Hammond, Professor-emeritus, Department of
Community and Family Medicine and the Department of Biomedical
Engineering, Duke University, immediate past President of the American
Medical Informatics Association, and Vice Chair of the HL7 Technical
Steering Committee, described the progression of health IT standards
from the past to the present, and his hopes for where they will go in
the future. Larry Garber, medical director for informatics and a
physician at Fallon Clinic, and Arthur Davison of the Colorado Health
Information Exchange, described those organizations' experiences in
developing regional health information networks.

### discussion points

-   In the past, standards were not a priority, as technology did not
    exist at a mature enough stage to use them. Now, however, technology
    is ripe for applications, but standards are still not being
    developed and used as they ought to be.

-   Standards start with the smallest element -- data.

-   It is important to recognize that standards are necessary but not
    sufficient. Beyond data standards, we will need to address
    processes, procedures, and have functional associations and sharing
    agreements to use them.

-   For any EHR system, it is critical that it can reliably match the
    records of the same patient at different encounters.

-   Patient matching is a very difficult task, and there are many ways
    of approaching it.

### key challenges

-   Data sharing fears.

-   Vendors are still legacy-oriented -- this is a source of many
    complaints with their systems.

-   HIPAA versus state regulations. State rules vary widely, and in
    areas such as New England where patients travel and institutions
    collaborate across state lines, it is especially important to be
    sure data security adheres to the strictest standards.

### key insights/lessons

-   Technology moves too fast to plan: we can't plan to solve the EHR
    problem 10 years from now based on technology we can't predict. We
    need a basic language that can be applied to any technology.

-   Interoperability based on common data standards is a pre-requisite
    for sharing and aggregation of data. The problem is that vendors and
    institutions, and even various departments within the same facility,
    are not interoperable.

-   The Master Patient Index (MPI) must be comprehensive, and must also
    guard patient's information privacy. You must avoid \"incidental
    disclosures," where a provider sees private information about the
    wrong patient in making matches.

-   The strategy employed by Garber and Davidson's groups is that each
    participating institution retains ownership of its own data, which
    in turn feeds the MPI via proxy servers that are within each
    organization's firewall, thereby protecting security.

## ^■^ III. Implementation and Training Strategies for SUCCESS ■

Two AHRQ grantees presented their experiences and strategies in
successful training strategies for health IT implementation. Dan Mingle,
project director of Maine General Medical Center's Outpatient Electronic
Health Record implementation project, and Rebecca Bradley of the
Louisiana Rural Health Information Technology Partnership described
their projects' strategies for training and rollout. They highlighted
insights gained from the process, both for training uses and for buy-in
to the systems.

### discussion points

-   Training is a never-ending story: you never finish, but you can get
    through it.

-   Every institution is different, every user is different. Spend time
    learning about each facility involved, and make sure trainings are
    suited to the environment and address different learning styles and
    abilities.

-   Many vendors will do a technical survey before rollout to make sure
    everything is adequately configured.

-   It's also a good idea to send a workflow specialist to each
    location.

-   Manage expectations.

### key challenges

-   Language barriers -- IT staff doesn't necessarily speak "nurse," and
    vice-versa.

-   Support needs grow quickly. You must keep up with increased
    staffing.

-   There will always be some resistance to new procedures and
    technologies.

-   There can be no downtime in the hospital. If you don't have
    real-time functionality, no one will use the system.

-   All facilities have competing projects. Make sure yours has
    dedicated staff, funding, etc.

### key insights/lessons

-   Examining previous computer usage by personnel is one way to predict
    buy-in. Surveys of willingness to learn can help identify greater
    training and encouragement needs.

-   RNs should train RNs and LPNs and CNAs separately and doctors should
    train doctors.

-   Place system in the ED and allow users to "play with it" using dummy
    data. This not only lets them get used to the system, but also
    allows assessment of typing skills, ease of use, etc.

-   Staffing is critical; your staff needs to have been hired and
    trained before you go live. You will probably need extra help --
    trainers, hardware support, software support, etc. -- so be
    prepared.

-   Keep paper records in parallel to electronic ones at first to work
    out bugs.

## ^■^ IV. Insights on New TECHNOLOGIES ■

Three leaders in the field of health IT presented different aspects of
technologies and considerations involved in health IT adoption. Chris
Gervais, a Senior Research Analyst/Technologist at Partners HealthCare,
described emerging wireless technology trends and how they affect IT
integration into practice. Paul Biondich of the Regenstrief Institute
presented "hammer and nail" approaches to health IT, describing a
variety of technologies and how they can play a role in improving care.
Shaun Grannis, of the Regenstrief Institute, described the workings of
the Indiana Network for Patient Care patient matching system. These
three presentations addressed the core nuts-and-bolts of health IT,
which is the hardware and software that make it all possible.

### discussion points

-   Today the spectrum of wireless devices, standards and methods of
    access span from micro to macro, from RFID chips providing
    identification within a personal network space to WiMAX providing
    broadband wireless access to metropolitan-sized regions.

-   It's easy to get lost in "wireless soup" of buzzwords -- LAN, WAN,
    WiMAX, ZigBee, BlueTooth, 802.11, etc. It's important to keep in
    mind that one technology is unlikely to be practical for all uses,
    and that finding a device that works is what is critical.

-   Hospital data fragmentation is recapitulated in the community, and
    efforts towards a community and nation-wide electronic health record
    must address this. Patients receive care at multiple institutions,
    and their records at these must all come together to form an EHR.

-   There are many ways to accomplish record linkage.

### key challenges

-   Wireless network security -- user authentication, data encryption

-   Wireless device battery life.

-   MPI cannot compromise patient data security, but must provide users
    with enough information to be confident of matches.

### key insights/lessons

-   Wireless is coming; soon there will be broadband wireless
    everywhere.

-   IT is a tool no different than a tongue depressor or otoscope, and
    may not be the best solution to all problems.

+----------+-----------------------------------------------------------+
|          | # G. FUNDING AND MANAGING HEALTH IT PROJECTS              |
+----------+-----------------------------------------------------------+

Lisa Dolan-Branton, RN, U.S. Public Health Service/AHRQ, and Daniel S.
Gaylin, MPA, Senior Vice President and Director of NORC's Department of
Health Survey, Program and Policy Research; Co-Director of the AHRQ NRC
co-chaired this track. They brought their extensive expertise in
developing and supporting Health IT applications and assessing health
information technology use among Community Health Center networks to
bear on this track. The track focus was on obtaining funding for health
IT projects and once you have a project -- how do you launch it? Manage
it effectively? And ensure that it achieves its desired outcomes? Over
the period of two days, four sessions were held: *Health IT Project
Management 101: Getting Started and Staying on Track; Managing Health IT
in the Real World, Challenges and Solutions; Funding Health IT,
Government, Foundation, and Payer Perspectives;* and*, a Mock Evaluation
Panel*, which looked at the federal grant making decision process.

High level insights and findings from this track include the following:

-   There are a myriad of funding opportunities but they are not well
    integrated.

-   It is difficult for an entity to understand how to position itself
    for specific opportunities, build proper partnerships, and write
    good grants.

-   The key is not only having a good idea but knowing the specific
    programmatic interest of funders.

-   On managing projects, key challenges brought forth were choosing a
    vendor, defining a systematic work plan, workflow, staff roles and
    responsibilities, implementing and evaluating one's project
    simultaneously, understanding project issues based on scale of
    project, obtaining buy-in from key stakeholders, especially
    physicians, workflow impact and tackling privacy and security
    issues.

## ^■^ I. Health IT Project Management 101: Getting Started and Staying On Track ^■^

This session examined key elements of project management and issues such
as: project start-up tasks; putting together a successful project
management team; initial vendor procurement and management; strategies
for managing an ongoing roll-out; and special challenges and approaches
for handling health IT projects in rural settings. There were three
panelists in this session. William Gaud (Will Gaud & Associates, LLC)
discussed the electronic medical records procurement process in terms of
problem definition, needs requirements, product viability, vendor
evaluation, RFPs, contract negotiation, and planning for implementation.
Alex Romillo (Health Choice Network) discussed ways to plan and
implement successful collaborative IT projects. Michael Rodriguez (John
Snow, Inc.) discussed approaches for managing health IT projects in
rural settings.

### discussion points

-   Understanding goals/the problem(s) that the project is to solve is
    an essential first step in the procurement process.

-   Know that you have a viable IT infrastructure in place to support
    your desired project before you embark on it. For example, what
    staff will support the project? Who is going to conduct ongoing
    training?

-   Assessing vendor qualifications involve looking at financial
    backgrounds, experience, and success in supporting various
    functional specifications; and ensuring that a contract includes
    favorable terms.

-   Focus on building trust among stakeholders through purposeful
    collaboration.

-   Managing health IT projects in rural settings requires knowing that
    oftentimes there are limited healthcare access options; information
    is inconsistent, chronic healthcare conditions abound, and "old
    fashioned" healthcare is often provided.

### key challenges

-   Selection of a vendor.

-   Identifying a "clinical champion," having on board an experienced
    project manager, and ensuring that there is a viable project plan.

-   Having the ability to manage expectations, understanding that there
    is no "perfect system."

-   Getting your organization and its staff to adapt to change.

-   Instituting IT in a rural healthcare setting could mean overcoming
    cultural barriers, financial constraints, and systemic barriers.

-   Educating and involving all key stakeholders; engendering their
    trust.

### key insights/lessons

-   Clinician participation is a must; remember that the objective is to
    define IT functionalities to meet clinician needs; but one must not
    forget about the patients.

-   The vendor is as important as the product.

-   Do not sign a contract until an agreed-upon project plan is
    delivered and contract terms are favorable to you.

-   Learn from others -- extract lessons from those who have experienced
    many of the same problems confronting you.

-   Provider education around health IT is key.

-   Be willing to change direction when new ideas that appear feasible
    come along.

## ^■^ II. Managing Health IT in the Real World: Challenges and Solutions ^■^

Grantee panelists John Branscombe, RRT, MSB (Aroostook Medical Center,
ME), Donald Crandell (Trinity Health, MI), and Lynn Volk (Partners
Healthcare System, MA) described their projects and the difficult
project management challenges they have had to overcome. These included
managing collaborative planning, rolling out CPOE across multiple
hospitals in a rural setting and simultaneously implementing and
evaluating health IT. John Branscombe's project utilized the chronic
care model to advance the sharing of medical information electronically
to improve quality and safety in patient care. Donald Crandall of
Trinity Health, the sixth largest tax-exempt health system in the U.S.,
discussed their Project Genesis initiative. The vision of Project
Genesis is to unite state-of-the art computer systems with best practice
business process in three areas: clinical, revenue cycle and supply
chain. Lynn Volk discussed the challenges of introducing evaluation into
their health IT implementation process that involved many practice sites
across different institutions.

### discussion points

-   There are many strategic benefits to using a clinical disease model
    including creating a synergy among participants, creating increased
    awareness and knowledge regarding technology applications, and
    allowing participants to engage in a health IT project at their own
    level.

-   Effective IT implementation requires undergoing a readiness process
    that may take 20 to 24 months.

-   One can't manage or improve what you can't measure; thus, it is
    important to plan and define evaluation baselines and tools that
    will aid in identifying required improvements as well as create
    flexible decision support and management environments.

### key challenges

-   Staying flexible during the planning phase.

-   Being aligned with state, community and regional activities.

-   Taking the time to carefully coordinate required activities.

-   Communicating with geographically distant partners.

-   Being able to quickly and efficiently resolve technical issues that
    come up when rolling out an IT implementation.

-   Identifying local M.D. champions.

-   Creating various and "safe place" learning venues for various types
    of users, especially clinicians.

-   Introducing evaluation into an IT project implementation
    environment.

-   Identifying an experienced project management team to lead and
    support IT health initiatives.

### key insights/lessons

-   Realize that clinical benefits of transformational change are a
    function of time and a result of engaging in a defined staged
    process.

-   Communicate early and often -- evaluation needs "sell" as much as
    the implementation.

-   Allow for a flexible timeline.

-   Pilot test everything that you can.

-   Address how various types of issues (technical, administrative,
    managerial, content, clinical, and private) impact data files.

-   Real advances occur through sharing of medical information
    electronically, and utilizing a chronic care model is a good way to
    facilitate this.

-   Create a project "charter" specifying mission, goals, and targeted
    outcomes, along with empowering key staff within partner
    organizations is key to success.

## ^■^ III. Funding Health IT: Government, Foundation and Payer Perspectives ^■^

Despite the growing body of evidence that quality, safety and efficiency
improvements can be achieved through the use of health IT, adoption
rates by practicing clinicians, hospitals and other healthcare providers
continue to be low due to a range of issues. Chief among these is the
financial impact of health IT. This session looked at the various
sectors interested in funding health IT. Information on current programs
and potential strategies for sustainable and synergistic funding were
discussed by a team of panelists who represented various funding
organizations. They included Lamott DuPont (Office of the National
Coordinator for Health Information Technology); Veenu Aulakh (California
HealthCare Foundation); Winston Wong (Kaiser Permanente); Jane Stafford
(Tides Foundation); Laura Leinen (Blue Cross Blue Shield Association of
Massachusetts), and Stephen Downs (Robert Wood Johnson Foundation)

### discussion points

-   With a national focus on regional health information exchange, there
    are a now a number of opportunities to obtain funds through key
    federal agencies including Agency for Healthcare Quality & Research
    (AHRQ), Center for Medicare and Medicaid Services (CMS), Health
    Resources and Services Administration (HRSA), which includes the
    Office for the Advancement of Telehealth, the Office of Rural Health
    Policy, and the Bureau of Primary Health Care, Office of the
    National Coordinator for Health Information Technology (ONCHIT),
    Department of Agriculture's Rural Utilities Program, Department of
    Labor, and University Service Fund-Rural Healthcare Division.

-   Five attributes of a successful applicant/grantee are:
    Vision/leadership, Collaboration, Data skills/knowledge, Technology,
    Infrastructure/funding.

-   A look into the future: Pay-for-performance programs, legislation to
    encourage development of a national health information
    infrastructure, including adopting electronic records, EHRs in place
    within 10 years, an increasing commitment for changing the
    day-to-day world of health care with health IT from leadership
    across sector, an expansion of the office of the National
    Coordinator for Health Information Technology, improved reporting of
    clinical results, reduced disparities, improved preventive care and
    improved population management.

### key challenges

-   Identifying, educating, and stimulating stakeholders to adopt and
    use health IT to improve quality of care and decrease costs.

-   Matching your ideas and capabilities to the specific programmatic
    interests of funders.

-   Forming sustainable strategic partnerships to pursue opportunities.

### key insights/lessons

-   Partner with others -- particularly bring together people and
    organizations that would not normally come together but together can
    make a difference.

-   Don't overlook safety net providers as potential partners.

-   Few unsolicited proposals are funded.

-   Tailor your funding proposal to a priority area of interest to a
    funding source.

-   Proposals should be patient-centric, emphasizing that they are at
    the heart of all operations.

-   Cost sharing is a way to build financial sustainability.

## ^■^ IV. Mock Evaluation Panel, Health IT Implementation Projects ^■^

Daniel Gaylin (NORC); Atif Zafar (Indiana University/Regenstrief
Institute); Tom Lewis (Maryland Primary Care Coalition); and Lisa
Dolan-Branton (AHRQ) served as a panel to present a simulation of a
government review panel in operation. The session gave attendees an
insight into the main activities of a government review panel, key
players and their roles, the evaluation process, and evaluation outputs.

### discussion points

-   Study section panel: Comprised of a standing panel of experts
    primarily from research environment, e.g., informatics experts,
    rural health. Panel analyzes the proposal and gives it a score.
    Review criteria are not weighted.

-   Special Emphasis Panel: Multidisciplinary experts assembled for one
    specific RFP. A scientific review administrator assigns 3 reviewers
    to a single application, tries to emphasize an objective process

-   Role of Government is to provide clarifying information and
    facilitate the review, including assigning reviewers.

-   Program Administrator Role: To be knowledgeable about the RFA and
    answer questions as needed.

-   Review criteria must be published. They differ across agencies.

-   Rating scale ranges from 1 to 5, with 1 being the highest and 5 the
    lowest.

-   Every agency has a different formula/bar for projects they will
    fund.

-   Can suggest whether a budget is adequate or inadequate, but grants
    management does an in-depth budget analysis.

-   Role of Panel Chair-- Introduces primary reviewers; keeps review
    running on time; serves as a reviewer, but does not necessarily
    comment on the grant application.

-   Primary Reviewers -- Discuss proposal in depth, analyzing both
    strengths and weaknesses.

-   Secondary Reviewers -- Usually 1 or 2 people on panel who will limit
    their comments to new points and new information.

### key challenges

-   Determining strengths -- proven model? Sustainable?
    Strong/experienced project leadership and key staff? Proven model?
    Innovative? Human subjects? Methodology?

-   Determining weaknesses -- Clear workflow? Too broad of a scope?
    Unclear evaluation plan? Suitable environment? Inadequate budget for
    work proposed?

-   Quick logistical process, but sometimes discussions not adequate
    enough due to time constraints.

### key insights/lessons

-   Project should be able to demonstrate a true understanding of the
    issues and present realistic and clear strategies.

-   Sustainability of project needs to be addressed.

-   A good, clear proposal abstract is important as reviewers will read
    it first to gain an overall understanding of the project.

-   Does the project address impact and how it will make a difference in
    the care of the patient?

-   Discuss security and privacy risks and how they will be mitigated.

-   Collaborative partnerships with other entities (particularly those
    that are generally competing with you) will be looked upon
    favorably.

-   Project should be able to demonstrate a compelling need for it and
    present an innovative approach.