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Patient Safety and Health Information Technology E-Newsletter

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October 12, 2005, Issue No. 13

Quote of the Month

"Patients are more at risk when nurses work long hours. A tired nurse is more likely to miss subtle changes, have more difficulties concentrating, and may not catch their own or others' errors."

—Ann E. Rogers, Ph.D., R.N., Associate Professor, University of Pennsylvania

(Select for more information about research on the effect of working hours on nurses by Dr. Rogers and her colleagues)

Today's Headlines:

  1. HHS awards more than $22.3 million to implement health IT systems
  2. Errors in cancer diagnosis put many patients in harm's way, according to AHRQ patient safety researchers
  3. AHRQ patient safety grantee Dr. Rogers and her colleagues examine the effect of nurse fatigue on the incidence of medical errors
  4. AHRQ patient safety research finds low electronic health record adoption rate for physician groups
  5. NQF and JCAHO announce 2005 John M. Eisenberg patient safety and quality awards
  6. New RFA for electronic prescribing standards announced
  7. Update on AHRQ Director's recent health IT speeches and articles
  8. HHS awards contracts to advance nationwide interoperable health IT
  9. Workflow differences may explain why small physician practices are less likely to adopt health IT products and services
  10. National Quality Measures Clearinghouse™ features patient safety-related measures
  11. AHRQ in the Patient Safety Professional Literature—Some Useful Citations

1.  HHS Awards More Than $22.3 Million to Implement Health Information Technology Systems

HHS recently announced $22.3 million in grants to implement health information technology systems to improve the safety and quality of health care. Awarded by AHRQ, the 16 new projects will focus on sharing health information between providers, laboratories, pharmacies, and patients, helping to ensure safer patient transitions between health care settings, as well as reducing medication errors and duplicative and unnecessary testing. In addition, AHRQ awarded nearly $5 million in contracts to implement a Statewide network of shared medical records in Delaware and to identify and support the planning of regional data sharing and interoperability activities in New York. These awards build on AHRQ's $25 million portfolio for developing Statewide and regional networks that are secure, ensure privacy of health information, and make an individual's health information more available to health care providers. The projects will contribute to AHRQ's capacity to learn from health IT implementation in clinical settings and to use the results from these real-world laboratories that are crucial to moving forward with broader implementation of health IT in American health care. AHRQ's investment in health IT now totals more than $166 million. Select to read the HHS press release.

2.  Errors in Cancer Diagnosis Put Many Patients in Harm's Way, According to AHRQ Patient Safety Researchers

Researchers found errors in the analysis of nearly 12 percent of non-gynecologic patient specimens and 9 percent of gynecologic patient specimens. The analyses were done to determine the presence or absence of cancer or precancerous lesions. Based on these results, researchers can conclude that at least 128,000 patients are potentially harmed unnecessarily each year in the U.S. Led by Stephen S. Raab, M.D., University of Pittsburgh School of Medicine, researchers reviewed tissue specimens, pathologists' findings, and medical records from four institutions that diagnose precancerous and cancerous lesions. Dr. Raab and his colleagues found that the majority of errors were a result of suboptimal specimen collection and misinterpretation of reviewed specimens by pathologists. Select to read the details of the AHRQ-funded study (grant no. HS13321), "Clinical Impact and Frequency of Anatomic Pathology Errors in Cancer Diagnoses," published in the October 10 online issue of Cancer.

3.  AHRQ Patient Safety Grantee Dr. Rogers and Her Colleagues Examine the Effect of Nurse Fatigue on the Incidence of Medical Errors

Long work shifts, including the 12-hour shifts worked by the majority of hospital nurses in this country, greatly increase the risk of making a medical error, according to AHRQ researchers who used data from national samples of over 900 nurses. AHRQ patient safety researcher Ann E. Rogers, Ph.D., R.N., Associate Professor at the University of Pennsylvania, and her team of experts address adverse outcomes of fatigue on patient care by examining nurse work patterns, shift durations, and overtime. As lead investigator of the AHRQ-funded project (grant no. HS11963), Dr. Rogers is currently examining factors that influence sleep duration, including how long nurses are sleeping on work and non-work days, as well as the factors that make it harder for nurses to recover from sleep deprivation associated with long work shifts. For more information on Dr. Rogers' research, select to read an article on the effects of staff nurse fatigue and patient safety, and an article that examines whether nurse performance is compromised as a result of no work breaks.

4.  AHRQ Patient Safety Research Finds Low Electronic Health Record Adoption Rate for Physician Groups

A comprehensive study by the Medical Group Management Association Center for Research and the University of Minnesota School of Public Health has captured the current state of adoption of electronic health records by U.S. medical group practices. More than 3,300 medical group practices participated in the AHRQ-funded project, "Assessing Adoption of Health Information Technology." The research shows that just 14.1 percent of all medical group practices use an electronic health record, and just 11.5 percent indicated that an electronic health record was fully implemented for all physicians and at all practice locations. More significantly, the research shows that only 12.5 percent of medical group practices with five or fewer full-time-equivalent (FTE) physicians have adopted an electronic health record. The adoption rate increased with the practice size; groups with 6 to 10 FTE physicians reported a 15.2 percent adoption rate, groups with 11-20 FTE physicians reported an 18.9 percent adoption rate, and groups of 20 or more FTE physicians had a 19.5 percent adoption rate. The study was led by David N. Gans, Director of Practice Management Resources for MGMA, Englewood, CO, and John Kralewski, Ph.D., Wallace Professor, Division of Health Services Research and Policy, University of Minnesota in Minneapolis. Select for more information on their study (contract no. 290-00-0017), published in the Sept/Oct issue of Health Affairs and select to read the press release.

5.  NQF and JCAHO Announce 2005 John M. Eisenberg Patient Safety and Quality Awards

The National Quality Forum and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced the 2005 recipients of the annual John M. Eisenberg Patient Safety and Quality Awards. The honorees, by award category, were for Individual Achievement: Audrey L. Nelson, Ph.D., R.N., James A. Haley VA Hospital, Tampa, FL; Innovation in Patient Safety and Quality at a National or Regional Level: Maryland Patient Safety Center, and Innovation in Patient Safety and Quality at a Local or Organizational Level: Meridian Health, NJ and Sentara Healthcare, VA and NC. Select to read the JCAHO press release.

6.  New RFA for Electronic Prescribing Standards Announced

AHRQ, on behalf of CMS, announced a new Request for Applications to solicit applications to conduct a pilot test of electronic prescribing standards under cooperative agreements that will inform the implementation of the Medicare Prescription Drug Benefit. CMS intends to commit up to $6 million to fund these cooperative agreements, which will test initial standards for E-prescribing and how they interact with E-prescribing workflow. The pilot testing will be conducted for up to 12 months during calendar year 2006. The test results will be reported to Congress in April 2007 as mandated by the Medicare Prescription Drug Improvement Modernization Act of 2003 and used to develop final E-prescribing standards. Deadline for applications is October 25. Select to read the RFA.

7.  Update on AHRQ Director's Recent Health IT Speeches and Articles

AHRQ Director Carolyn M. Clancy, M.D., recently discussed the Agency's health information technology initiative and how it relates to quality improvement efforts and AHRQ's new Effective Health Care Program. Select to read the text of her speech, "Health Information Technology and the Quality Movement," presented at the Second Health IT Summit in Washington, DC, on September 9. Also, a September 12 special edition of Government Computer News magazine examines the potential for health IT to improve quality of care and patient safety. In a column written for the magazine, Dr. Clancy summarizes the quality-of-care improvements that health IT can offer and explains AHRQ's special role in helping prepare health care professionals for the new world of health IT. Select to read the column. The magazine also includes a question-and-answer forum featuring Scott Young, M.D., director of AHRQ's health IT program. Select to read the forum.

8.  HHS Awards Contracts to Advance Nationwide Interoperable Health IT

Recently, HHS announced the award of $17.5 million in contracts to public and private organizations that will use the funds to accelerate the adoption of health information technology and the secure portability of health information across the United States. These organizations will form strategic partnerships to develop the building blocks necessary for achieving the President's goal of widespread adoption of interoperable electronic health records within 10 years. The projects funded under these contracts will create and evaluate processes for harmonizing health information standards, develop criteria to certify and evaluate health IT products, and develop solutions to address variations in business policies and State laws that affect privacy and security practices that may pose challenges to the secure communication of health information. Under the contracts, these partnerships report to the American Health Information Community, a new Federal advisory committee that is chaired by Secretary Leavitt and charged with providing recommendations to HHS on how to make health records digital and interoperable. Select to read a statement by HHS Secretary Mike Leavitt issued last week about the first meeting held by AHIC and select to read the HHS press release about the awarded contracts.

9.  Workflow Differences May Explain Why Small Physician Practices Are Less Likely To Adopt Health IT Products and Services

Researchers and other experts have found that diverse delivery systems and complex workflows within small physician practices are poorly addressed by current standardized health IT systems. This may explain why small practice settings are slower adopters of health IT products and services than are hospitals and larger practice settings. Earlier this year, the National Institute for Health Care Management Foundation convened a panel of leading national experts to help identify the barriers to health IT adoption by small physician practices. As a result of the AHRQ-sponsored conference, issues on the importance of financing and interoperability, as well as office workflow and how tasks are organized and resources used to achieve outcomes, were addressed. Findings and lessons learned from the conference are now published in the Sept/Oct 2005 issue of Health Affairs. Select to access the article, "The Adoption Gap: Health Information Technology in Small Physician Practices," by Jason Lee, Ph.D., and Nancy Chockley of the NIHCM Foundation, and AHRQ's Carol Cain, Scott Young, M.D., and Helen Burstin, M.D., in PubMed®.

10.  National Quality Measures Clearinghouse™ Features Patient Safety-Related Measures

More than 40 of the approximately 700 quality measures included in the National Quality Measures Clearinghouse™ have been categorized in the Institute of Medicine's domain of "safety." The NQMC team classifies a measure as patient safety-related when safety applies to the measure's primary clinical component. In addition to the AHRQ Patient Safety Indicators, measures from the Veterans Health Administration, Institute for Clinical Systems Improvement, Physician Consortium for Performance Improvement, and the Accreditation Association for Ambulatory Health Care Institute for Quality Improvement are classified as safety in NQMC. To find these safety-related evidence-based measures, use the detailed search feature at (scroll approximately two-thirds down, select "safety" in the IOM Domain field box, scroll to the bottom of page, and select Search).

11.  AHRQ in the Patient Safety Professional Literature—Some Useful Citations

We are providing the following hyperlinks to abstracts of journal articles describing AHRQ-funded research. Unfortunately, some of you may not be able to access the abstracts because of firewalls or specific settings on your individual computer systems. If you are having problems, you should ask your technical support staff for possible remedies.

Dowell D, Manwell LB, Maguire A, An PG, Paluch L, Felix K, Williams E; MEMO Investigators. Urban outpatient views on quality and safety in primary care. Healthc Q 2005;8(2):suppl 2-8. Select to read the abstract in PubMed®.

Rosen AK, Rivard P, Zhao S, Loveland S, Tsilimingras D, Christiansen CL, Elixhauser A, Romano PS. Evaluating the Patient Safety Indicators: How Well Do They Perform on Veterans Health Administration Data? Med Care 2005 Sep; 43(9):873-84. Select to read the abstract in PubMed®.

Ursprung R, Gray JE, Edwards WH, Horbar JD, Nickerson J, Plsek P, Shiono PH, Suresh GK, Goldmann DA. Real time patient safety audits: improving safety every day. Qual Saf Health Care 2005 Aug;14(4):284-9. Select to read the abstract in PubMed®.

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Current as of October 2005


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