patient safety and health information technology
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Number 621 (Replaces Committee Estimation Number 472, November 2010)Committee on Patient Safety and Quality ImprovementCommittee on Practice ManagementThis document displays rising ideas on affected person safety and is problem to change. The data have to now not be construed as dictating an extraordinary course of remedy or manner to be followed.
Number 621 (Replaces Board Opinion Number 472, November
2010)
Committee on Patient Safety and Quality Improvement
Committee on Practice Management
This record reflects emerging concepts on affected person protection and is issue to alternate. The records must no longer be construed as dictating an extraordinary route of treatment or manner to be accompanied.
ABSTRACT:
The blessings of fitness records generation (IT)
consist of facilitating verbal exchange between fitness care carriers;
enhancing remedy protection, monitoring, and reporting; and selling first-class
of care via optimized access to and adherence to recommendations. Health IT
structures allow the gathering of records to be used for exceptional
management, final results reporting, and public health disease investigation
and reporting. However, improvement is wanted with all health IT, especially
concerning design, implementation, and integration among structures in the work
surroundings. Robust interoperability is important for secure care, but this
intention has proved elusive. Significant patient safety concerns already have
been diagnosed; it's miles essential to hold affected person safety and
first-class as the number one attention.
Benefits of Health Information Technology
Most obstetrician–gynecologists are actually using digital
health information. They have hastily moved into use due to the recognition of
their capacity blessings and authorities programs that incentivize their use.
The benefits of fitness facts technology (IT) encompass its potential to keep
and retrieve information; the capacity to unexpectedly communicate affected
person facts in a legible layout; progressed medication protection thru
accelerated legibility, which probably decreases the risk of medicine mistakes;
and the benefit of retrieval of affected person records.
The capability to enhance affected person protection exists via the use of drugs indicators, medical flags and reminders, better specialist care and reporting of consultations and diagnostic checking out, scientific choice guide, and the provision of whole affected person records. Data accrued via the use of health IT may be used to evaluate the efficacy of therapeutic interventions and had been demonstrated to result in improvements inside the exercise of medicine 1. Alerts can optimize adherence to suggestions and proof-based totally care 2. Record uniformity can be designed to reduce exercise versions, behavior systematic audits for excellent assurance, and optimize evidenced-primarily based take care of not unusual situations three.
Health IT is growing affected person engagement as
purchasers of fitness care. It lets in sufferers get entry to to their
scientific statistics, which facilitates them to sense more informed
approximately their situations and encourages them to actively participate in
shared choice making.
Outside the patient stumble upon, it may enhance observe-up
for missed appointments, consultations, and diagnostic trying out. A health
care company can look for precise cohorts of patients inside a practice to
screen and improve adherence to indicated fitness care together with
mammograms, Pap tests, or measurement of hemoglobin A1c ranges.
Patient Safety Concerns With Health Information Technology
In the 2013 list of hazards with the aid of ECRI Institute,
4 of the top ten hazards have been immediately related to fitness IT.
“Technology-associated damaging events can be associated with all components of
a comprehensive generation system and may contain mistakes of both fee or
omission. These accidental unfavourable occasions typically stem from
human-device interfaces or organisation/machine design” four.
The use of alerts to warn fitness care carriers of potential
troubles is a effective tool. However, indicators pinnacle the listing of 2013
fitness IT dangers due to the fact the sheer quantity of them is inflicting
alert fatigue. This trouble is complex and requires individualization inside
every facility. Developing structures to manage signals, establish ranges of
importance, and lead them to unambiguous is a important patient protection
priority.
Computerized Physician Order Entry has advanced legibility
and order processing instances, and reduced the risk of medical errors; but,
safety issues had been raised. The time had to region an order has extended,
the ordering procedure might also disrupt the paintings drift of the health
care provider, and a few formatting can create new opportunities for errors.
These mistakes may be as a result of fragmented shows, inflexible ordering
formats, incompatible orders, and separations in capabilities that save you
full comprehension of a patient’s health care needs 1.
Patient engagement equipment, even as improving patient
involvement, also introduce reliability worries regarding facts. Use of
transportable gadgets that aren't password covered makes the patient record weak
to invasion of privateness 5.
Patient records mismatch or placing statistics into the
incorrect patient’s chart or documenting affected person information under the
incorrect visit can be multiplied with electronic charting. Mismatches also can
occur with paper charting. However, as the amount of information being
transferred among one of a kind structures increases, the probable for mass
mismatch exists and must be evaluated.
Although robust interoperability could allow the alternate of patient statistics and availability of a complete image of the patient’s care, attaining any such aim has remained elusive. The alternate of statistics throughout all fitness care settings and fitness care carriers could reduce mistakes and enhance patient protection. However, the market continues to sell merchandise that use proprietary code and, for this reason, aren't effortlessly integrated with different structures for the change of facts.
Automated and self-populating templates designed to store
time can inadvertently reason inaccuracy inside the clinical document. Health
care carriers must overview and edit those templates to ensure that they
correctly replicate the come upon. Copying and pasting affected person notes
from prior visits also can compromise a patient’s document if not correctly reviewed
and edited.
There are many limitations to addressing patient protection
concerns within fitness IT systems. There is an absence of compulsory reporting
for scientific mistakes associated with health IT structures. The nature of
competing fitness IT providers is such that fitness care carriers might also
worry sharing mistakes directly related to the IT machine due to subject of
violating nondisclosure clauses and providers’ highbrow property rights signed
by way of customers 1.
Conclusion
Health IT has grow to be an essential part of the exercise
of medication. As with any new generation, health IT brings many ability
benefits and in addition to potential worries. The current literature to this
point, displays outcomes at unmarried web sites or institutions. National
estimates are extrapolations from these unmarried-site studies. As the
implementation and use of fitness IT systems growth, it's far important to
preserve patient safety and quality as a chief consciousness 6.
Resource
The following useful resource is for facts functions only.
Referral to this net web site does not mean the endorsement of the American
College of Obstetricians and Gynecologists. This resource isn't always supposed
to be comprehensive. The exclusion of a source or net website online does now
not mirror the nice of that source or net site. Please word that internet sites
are subject to change with out notice.
The Health Assurance Portability and Duty Act (HIPAA)
Privacy Rule. Http://www.Hhs.Gov/ocr/privacy/.
References
Copyright January 2015 by way of the American College of
Obstetricians and Gynecologists, 409 twelfth Street, SW, PO Box 96920,
Washington, DC 20090-6920. All rights reserved.ISSN 1074-861XPatient safety and
health facts technology. Committee Opinion No. 621. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2015;125:282–three.
Copyright January 2015 via the American Academy of Accoucheurs
and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC
20090-6920. All rights reserved.
Patient protection and fitness records era. Committee Opinion No. 621. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;a hundred twenty five:282–three.
