Sociotechnical Models for Safety in Health IT

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By Susan Carr

Patient safety has been a topic of interest at the annual HIMSS conference for the 10 years that I have attended and probably longer. Safety improvement usually appears on the program and in discussion as the result or at least the goal of technology implementations. Since at least 2012, safety problems have also been discussed as the unintended consequences of technology. Although recognized as a valuable tool for safety improvement, technology also presents new opportunities for doing harm. While there seems to be a basic understanding and acceptance of that rule, a deeper appreciation for the complexities of the role of technology, especially health information technology (IT), gained a place at this year’s HIMSS conference.

First, some background. The percentage of practices and hospitals that are using electronic health record (EHRs) has grown quickly since the HITECH Act of 2009 established financial incentives beginning in 2011 for implementation and “meaningful use” of EHRs. During these years, the number of people attending the annual HIMSS conference also grew, from more than 31,000 in 2011 to more than 38,000 this year. The exhibitor floor likewise continues to grow. In roughly the same timeframe, the Institute of Medicine (IOM) established a committee to study patient safety and health IT. In November 2011, the IOM published Health IT and Patient Safety: Building Safer Systems for Better Care, which explores both the risks and rewards of health IT.

In February 2012, I reported on a presentation I had attended at HIMSS given by David Classen, MD, a member of the IOM committee on safety and health IT. Classen spoke to an overflow crowd, and my blog post post drew more traffic than any post I’d published previously. Although there was and is great interest in the topic, it’s not clear that safety has improved.

This year, HIMSS offered a full-day, pre-conference program called “Patient Safety: Making Healthcare Safer—IT Challenges and Solutions.” Classen was again part of the program and opened the day with a keynote titled “Applying Safety Science to Health IT.” In it, he stressed the importance of the “sociotechnical model” as a framework for approaching health IT as only one component of our large, complex healthcare delivery system. For significant, endurable improvement, we must understand and address the system as a whole. That theme continued through the day.

The IOM report on health IT describes the sociotechnical model as consisting of:

  • Technology, including health IT hardware and software;
  • People, including all who work in the system, contributing their knowledge, skills, and vulnerabilities;
  • Process, meaning the workflows, procedures, and interactions that comprise healthcare delivery;
  • Organization, including the goals and priorities that are in play as organizations make choices about investing in and using technology; and
  • External environment, which refers to certifications and regulations that affect choices and implementation (p. 61–63).

This systems approach is important for all safety improvement efforts, not just for health IT, and it isn’t new. To Err Is Human, the IOM report widely credited with launching the modern patient safety movement, identified the complexity of our healthcare system as a root cause of risk and concern:

Some systems are more prone to accidents than others because of the way the components are tied together. Health care services is a complex and technological industry prone to accidents (p. 65).

The patient safety movement has benefitted from the work of experts including psychologists James Reason and Karl Weick, human factors expert Sidney Dekker, anesthesiologist Richard Cook, and many others who have studied the role of complexity and systems in patient safety. As we learn more about how to use health IT for safety improvement and how to protect patients from unintended consequences, we’re reminded that health IT is no different from other component pieces of the healthcare system. The sociotechnical model applies across all safety efforts. In “A Sociotechnical Model for Pharmacy,” Classen and Brown argue that safety must be managed as a pervasive, integral part of any complex system, not as an isolated component.

[in 2000]…there was almost magical thinking that technology in the form of electronic health records (EHRs) would erase medication safety issues entirely, if only they were widely adopted (p. S1).

They go on to say,

It is imperative that health care organizations depart from the notion of safety management as something that can be achieved through a succession of narrowly defined “safety projects” that address surface manifestations of adverse component interactions—that is, the phenotype rather than the genotype, the component rather than its interactive context (p. S4).

Time spent learning about systems and complexity will benefit all safety improvement efforts, not just those aimed at promoting the safe use of health IT.

References

Institute of Medicine. Committee on Patient Safety and Health Information Technology. (2012). Health IT and patient safety: Building safer systems for better care. Washington, DC: The National Academies Press.

Institute of Medicine. Committee in Quality of Health Care in America. (2000). To err is human: Building a safer health system. L. T. Kohn, J. M. Corrigan & M. S. Donaldson (Eds.). Washington, DC: The National Academies Press.

Classen, D. C., & Brown, J. (2013). A Sociotechnical model for pharmacy. Hospital Pharmacy, 48(Suppl 2). doi: 10.1310/hpj4803-S1.