IT. HIT. HIM.
Is this an emphatic description of someone having a sudden realization?
These acronyms are becoming pretty common in our daily work in health care. Throw in an ACK, a CAT, and a SLIP, and you could have the beginning of a good story!
But, seriously—information technology (IT), health information technology (HIT), and health information management (HIM) are no joke. They’re essential components of today’s health care system.
You’ve probably also heard of health informatics, which links health information with other components, such as communication, to learn how to improve patient care. According to the Canadian Health Information Management Association (CHIMA), health information is more than just data—it’s a shared language that connects people to their care providers.
But what happens when the use of information technology in health care inadvertently creates risk or causes harm? What kind of risk or harm can result? And, how can we prevent it?
That’s what Chantelle Recsky and her colleagues at Vancouver Coastal Health (VCH) are determined to find out.
In 2018, Chantelle, an RN and doctoral trainee at the UBC School of Nursing, was awarded a Health System Impact Fellowship by the Canadian Institutes of Health Research (CIHR).
The fellowship provided an opportunity for Chantelle to conduct research on the impact of technology on patient safety. As part of her research, Chantelle has been helping her VCH partners use BC Patient Safety & Learning System (PSLS) data to identify safety concerns, promote a culture of safety, and encourage continuous improvement.
Pretty cool, right?
Under the supervision of Leanne Currie, PhD, RN, associate professor at the UBC School of Nursing, and in partnership with the VCH Quality and Patient Safety and Clinical Informatics teams, Chantelle is focused on the community care setting as the area for her research.
“A lot of the research so far has been in the acute setting,” says Chantelle. “There is still a lot to learn about how technology can impact patient safety, especially in community and primary care settings.”
Patient safety incidents related to information technology can involve electronic health records, electronic notifications and reminders, medication ordering systems, and other computer systems.
They even have their own acronym.
A patient safety incident with a potentially negative outcome in which health information technology played a role is called a TMAE (technology-mediated adverse event).
TMAEs in the community
So, what do TMAEs look like outside of acute care?
“In non-acute settings, we may need to look at safety concerns a bit differently because the nature of health care services is different—it’s spread out more over time and space,” notes Chantelle. “There are unique safety risks, and we are continuing to learn more about what those risks are.”
Chantelle analyzed incidents reported in PSLS from VCH Community between November 1, 2016 and October 31, 2018. This review included home health, primary care, mental health, pharmacy, and public health.
Among the 105 reports where the computer system was identified as a factor, the most frequent type of incident was a medication problem or error and the most prevalent setting was public health.
“Medication events seem to be more easily recognized,” adds Chantelle. “But there are also more subtle incidents that we are learning about, like when the information available about a patient isn’t accurate and ultimately leads to missteps in their care. These are things we want to be attuned to.”
The data also suggested some interesting patterns.
For example, while the public health setting had the most reported incidents during this period, the majority of them resulted in no harm. In contrast, home health reported the fewest number of incidents, but over half of them resulted in minor or moderate harm.
Integrated knowledge translation
Chantelle currently works with the clinical informatics team for Vancouver Community, led by Jeb Dykema, to analyze and learn from events in real-time.
Jeb’s team supports over 7,000 VCH Community staff with their documentation, workflow, and use of clinical information.
“Chantelle brought the issues of quality and safety to the team,” says Jeb. “There are often incidents and near misses because of workflows, improper design, etc. Our team now has access to follow up PSLS events. We also input events that staff report to us verbally.”
VCH PSLS Coordinator Terri Aitken helped the team get started by providing handler training, data summary reports, and trouble-shooting when needed.
The team has been getting the word out about PSLS and the value of embedding it in the community culture. They analyze incidents related to information technology and make it a priority to provide feedback to staff who report issues.
For example, last year an issue arose when a nurse practitioner moved from a VCH clinic to a non-health authority clinic, but her lab reports continued to be sent to her VCH account. By the time the team became aware of the situation, over forty lab reports were sitting in the account, never having been seen or followed up on.
To prevent this from recurring, the team incorporated information about setting up accounts into onboarding and off-boarding packages for nurse practitioners and general practitioners.
“We only knew about this because someone reported it in PSLS,” says Jeb.
A paper-based community
What does all this research and knowledge translation look like from the clinical point of view?
Brit Hayward was the Clinical Coordinator for VCH’s Community Transitional Care Team (CTCT) in Vancouver’s Downtown Eastside before recently moving to another role.
The 9-bed CTCT program serves clients who require long-term antibiotic therapy, are connected to the Downtown Eastside community, and are actively using substances or have a past history with substance use.
Located in the Pennsylvania Hotel on Carrall Street, the program supports clients to complete their antibiotic therapy by providing a temporary residence where they can come and go as they please while staying compliant with medication and clinical appointments.
Photo credit: PHS Community Services Society
“The implementation of the electronic health record at St. Paul’s resulted in some miscommunication and missing information, because CTCT is still largely paper-based,” says Brit. “For example, discharge medication reconciliations were missing when clients were transferred from hospital. We deal with a population that uses prescribed opioids, so this information is crucial.”
Once that issue was reported in PSLS, Chantelle and the clinical informatics team became involved and they worked with the CTCT to figure out a solution. As a result, some VCH Community staff now have read-only access to patient information in the electronic health record and the team is working toward getting full access.
Depending on the type of incident reported in PSLS, the team may review reports internally and brainstorm solutions. If the issue involves a transfer from acute care or a documentation error, the PSLS report will go to the unit or program involved in order to loop them into the conversation.
“Without PSLS, we might not be having these kinds of conversations,” says Brit. “It raises the red flag.”
In addition to analyzing past and current PSLS incident reports and looking for ways to prevent incidents from recurring, Chantelle and the team are accumulating data over time to inform bigger decisions and system-wide improvements.
So, it’s important for staff to keep reporting incidents in PSLS, even during these challenging times.
For more information on this unique research partnership, check out this article from the Vancouver Coastal Health Research Institute.
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