AHRQ Reports on Software Designed to Identify Health IT Hazards
The Agency for Healthcare Research and Quality (AHRQ) has released a report that describes the development and testing of software designed to be used by health industry professionals to report, analyze, correct, and prevent hazards resulting from the use of health information technology (IT). The software—Hazard Manager—is not available while still under development and consideration. The report describes why the software was developed, the results of an extensive testing period, feedback received from various stakeholders, and options for national implementation.
Abt Associates, Geisinger Health System, and ECRI Institute worked under contract with AHRQ on the project. Abt built and beta-tested Hazard Manager and subcontracted with ECRI Institute to program and operate the web-based beta version of the software. The ontology on which Hazard Manager is based was previously designed and tested by Dr. Jim Walker, chief health information officer at Geisinger Health, where seven sites participated in the beta test. In addition, five health IT vendors and representatives from AHRQ, the Food and Drug Administration (FDA), and the Office of the National Coordinator for Health IT (ONC) participated in the testing. Dr. Walker and Abt Associates Project Director Andrea Hassol are authors of the report.
Hazard Manager is designed for “proactive hazard control.” Beyond the obvious imperative—to catch hazards before they cause harm—proactive hazard control supports patient safety by promoting systems thinking, multidisciplinary teamwork, creative vs. reactionary investigation, and engagement of the public. In Patient Safety and Health IT (2011), the Institute of Medicine called for the secretary of Health and Human Services to implement a process for proactive reporting (in addition to retrospective reporting) of hazards and adverse events caused by health IT.
The parties involved in the beta-test—healthcare organizations, health IT vendors, researchers, and regulators—constituted a “”learning community” built on the model of AHRQ’s Patient Safety Organizations, which used Hazard Manager to “support the creation of consistent, comparable information and support shared learning about hazards” associated with health IT.
The beta-test began with an informational webinar in April 2011. At the completion of the 6-month testing period, ECRI forwarded the database containing 495 hazard reports to researchers at Abt Associates for analysis. Two months later, in December 2011, AHRQ hosted a meeting to discuss refining the process of reporting and analyzing hazards as well as options for future deployment of Hazard Manager and its role in a national program for improving the safety of health IT. That meeting included individuals from the healthcare organizations and vendors involved in the beta-test and representatives from AHRQ, FDA, ONC and the Center for Medicare and Medicaid Services.