POLOS DE DESARROLLO

Safer use is intimately linked to safer design. For example, safer use of an EHR evolves from effective planning and deployment with testing and management of human–computer interface issues, to optimization of tools and processes to improve the application of the system. Users re- ceive education and skill development to learn the utility of the system and accept responsibility to report conditions that could detract from or enhance EHR functionality. Observation, mea- surement, and synthesis of lessons learned about the impact of EHRs on desired work patterns and outputs will help address deficiencies in the design, usability, and clinical behavior related to EHR products. Ensuring safer use relies upon evaluation of workload impact—ergonomic, cog- nitive, and data comprehension—and its effect on each clinician and the care team. There is a need for metrics to describe accurately user interactions with EHRs and other health IT devices that enable care (Armijo et al., 2009). For users, the opportunities to improve safety of health IT can be divided into the following phases: acquisition, clinical implementation (which includes planning and goal setting, deployment, stabilization, optimization, and transformation), and

maintenance activities (see Table 4-5). These stages create a continuous cycle that can be applied throughout the life cycle of health IT. The safety of health IT is contingent on each of these stag- es. An ongoing commitment to implementation is needed to realize safer, more effective care. It is an iterative process that requires ongoing learning and improvement based on the experience of users.

TABLE 4-5

Health IT User Activities

Activities/Phases Features Opportunities to Improve Safety Acquisition – Selecting and attaining

a system that will con- nect data from clinical and other related IT and support an organization’s clinical and administrative workfl ows

– Perform self-assessments and strategic planning before the decision to purchase health IT – Ensure that the resources

needed to support adoption and implementation of health IT products are available

Clinical Implementation

– Planning and goal setting • Assessing needs • Selecting systems

based on functionality • Testing quality before

go-live – Deployment

• Training and demon- strating competence of users • Converting data conversions prior to go-live • Minimizing mix of electronic and paper functions • Planning orderly implementation – Stabilization • Evaluating human- computer interactions for eff ective design and interface • Correcting functions

that disrupt workfl ow • Minimizing downtime • Planning maintenance – Optimization

• Engaging clinical decision support • Retraining for proper

and best use

• Readdressing changes needed for workfl ow improvements – Transformation

• Measuring improved clinical and effi ciency outcomes

– Analyze existing workfl ow, envision the optimal workfl ow, and select the automated system that achieves the optimal automated workfl ow – Establish mechanisms

and metrics to identify, escalate, and remediate patient safety issues – Testing locally to verify

safety, interoperability, security, and eff ectiveness – Monitor and measure the

dependability, reliability, and security of the installed system

– Take steps to resolve any potential hazards

– Learn and improve patient safety by utilizing data generated by the health IT system

TABLE 4-5 Continued

Activities/Phases Features Opportunities to Improve Safety Maintenance

Activities

– Activities are carried out to keep a system operational and to support ongoing use

– Schedule any needed downtown and upgrades in advance to minimize disruptions in workfl ow – Establish workfl ow proce-

dures for scheduled and/or unexpected downtime

Acquisition

The first activity for users is the decision to move from an existing environment or status quo to one that better serves the business needs and/or functionalities of the organization or practice. Delineation of business needs and drivers is the foundation of the IT strategy that propels the de- cision to acquire a system and initiates the acquisition process. Acquiring health IT requires a decision and commitment to change workflows within the organization. Designing new and ac- ceptable workflows, training staff, and dealing with consequential changes will be major drivers of cost and potential risk. Implementing a new health IT product is not an IT project, it is a quali- ty improvement and business change project facilitated by IT.

A needs assessment can help evaluate the current status and the future needs in relation to the health IT solutions targeted to close gaps in clinical, operational, and financial goals. After a need is identified, timelines for acquiring and implementing ought to be developed and an im- perative for change be created. Change management is complex and requires organizations to be aware of the potential downstream misalignments between the perceived functionality of health IT and the needs of the organization.

Acquisition requires a deliberative process to select and attain a system that will connect data from clinical and other related IT and support an organization’s clinical and administrative workflows. The organization wants to ensure an effective, safe implementation and not favor speed over quality; the number of systems being integrated may also affect the depth and volume of implementation support required. Similarly, the cost of a health IT product is often a major driver in the decision-making process but cost has to be balanced with quality of the product. Maintenance costs also need to be recognized. Unconstrained growth of requirements can result in changing project goals that can lead to frustration and schedule overruns.

Organizations should perform self-assessments and strategic planning before the decision to purchase health IT. Organizations need to consider their innovation temperance, or their toler- ance for risk, as well as the stability of the current process. Organizational infrastructure also needs to be considered to ensure that the resources needed to support adoption and implementa- tion of health IT products are available. Not only are the personnel resources and monetary re- sources important but also the technical resources needed to adopt the proposed technology, such as the ability to test the product and ensure functionality including interoperability with secure exchange of data. The characteristics of having a culture of safety, being a learning organization, having strong staff morale, and having adequate resources are critical to the successful adoption of health IT. These are especially important for smaller organizations with fewer resources to

consider in the adoption and decision-making processes. Much of the responsibility for these characteristics occurs at the senior leadership level, but driving change requires both administra- tive and clinical staff taking on delineated roles.

These antecedents to acquisition will help an organization prepare for both acquisition and implementation of health IT and optimize outcomes in subsequent phases of the implementation life cycle. Unfortunately, sometimes the due process of strategic planning is in place, but the eva- luative decision-making model is inadequate. For example, everyone’s opinions and feedback are acquired by the organization leaders, but, in the final decision, critical information from the clinicians may be weighted the least (Keselman et al., 2004).

Some of the generalizable traits organizations must demonstrate for achieving safer patient care have applicability to the use of health IT. Gleaned from sociotechnical industries such as aviation, nuclear power, chemical, road transportation, and health care, there are five systemic needs health care providers must satisfy to maximize safe performance, which are the needs to:

• Limit the discretion of workers,

• Reduce worker autonomy,

• Transition from a craftsmanship mindset to that of equivalent actors,

• Develop system-level (senior leadership) arbitration to optimize safety strategies, and

• Strive for simplification (Amalberti et al., 2005).

At times, these restraining forces are at odds with traditional values promoting autonomy, crea- tivity, academic expression, safety, and exercising professional judgment. They do, however, demand careful consideration to ensure the very individuals entrusted to provide safe care are not contributing barriers to safe care delivery.

An organization’s readiness to adopt health IT can impact the safety, suitability, and perfor- mance of the technology. Managing end-user expectations from the beginning will also help aid implementation. Clinicians expect technology to be perfect and deliver efficient and effective information just in time, every time, with little effort. Whereas most systems are able to perform at these levels, there will be times, such as initial implementation or unanticipated downtimes, that will challenge user patience. These factors need to be considered before implementation both to reduce burdens to the organization and to protect the organization from harming patients in the later phases.

Clinical Implementation

Successful deployment of a health IT product and its effective use are intended to achieve seamless internal information flow as well as to enhance performance in safety, quality, service, and cost. Safe implementation of health IT is a complex, dynamic process that requires continual feedback to vendors and investment by health care organizations. Merely installing health infor- mation technologies in health care organizations will not result in improvements in care.

Because each health care organization is different, each organization has different needs and makes choices resulting in varied, customized implementation. Poor implementation can result in the development of processes different from the intended use of a system, otherwise known as use error. As shown in Figure 4-2, implementation includes the stages of planning and goal set- ting, deployment, stabilization, optimization, and transformation.