OAKBROOK TERRACE, Ill. – July 2, 2013 – Today, The Joint Commission announced that it has received a sole source contract from the federal Office of the National Coordinator for Health Information Technology (ONC) to address one of the key recommendations made in the Institute of Medicine report, “Health IT and Patient Safety: Building Safer Systems for Better Care.” The report called for an independent entity to help indentify unsafe health information technology (health IT) conditions that have been associated with serious patient safety events, develop a process for preventing health IT-related adverse events, and educate the health care field and others about this work.
The primary objective of the contract is to establish a credible and meaningful process that can be used to identify, understand, disseminate and eventually help prevent health IT-related sentinel events that may cause serious or fatal harm to patients. The results of the work will inform ONC’s “Health IT Patient Safety Action and Surveillance Plan” to use health IT to make care safer and continuously improve the safety of health IT.
As a component of its accreditation services, The Joint Commission’s Office of Quality Monitoring (OQM) regularly receives reports of sentinel events, including health IT-related sentinel events, from accredited organizations. The OQM staff routinely works with organizations to review their root cause analysis and aggregates data to increase public knowledge about sentinel events, their causes, and strategies for prevention. To accomplish the goals of the contract, The Joint Commission will enhance the use of its de-identified data warehouse of the Sentinel Event Database, and its associated reporting process, as permitted by The Joint Commission’s contract with accredited health care organizations. Only the de-identified data warehouse will be used to fulfill the terms of the contract and no identifiable data will be shared or even accessed at any point. The de-identification of the data will involve removing any identifiable reference to the patient under HIPAA standards, practitioner, staff, and organization.
“We thank the ONC for providing us with the opportunity to work on this significant project addressing the safe adoption of health information technology to establish a process for preventing patient harm and death,” says Mark R. Chassin, M.D., FACP, M.P.P., M.P.H., president and CEO, The Joint Commission. “The Joint Commission recognizes that, in order to keep pace with the rapid adoption of health information technology, it is important to adequately and knowledgeably research the emerging issues surrounding any role technology may play in contributing to instances of serious patient harm. The Joint Commission has a unique opportunity to work with health care organizations and learn from the analysis of incidents of patient harm, death or near misses that are related to health information technology.”
Health IT devices include hardware or software that is used to electronically create, maintain, analyze, store, or receive information to aid in the diagnosis, cure, mitigation, treatment, or prevention of disease and that is not an integral part of an implantable device or an item of medical equipment. Devices can include:
- Administrative/billing or practice management systems;
- Automated dispensing systems;
- Electronic health records or component of electronic health records, including computerized provider order entry systems, pharmacy systems, electronic medication administration records, clinical documentation systems and clinical decision support systems;
- Human interface devices, such as a keyboard, mouse, touch screen, speech recognition system, monitor or printer;
- Laboratory information systems, including microbiology and pathology systems; and
- Radiology/diagnostic imaging systems, including picture archiving and communications systems.
Among the objectives of the contract for The Joint commission are to write a report identifying high priority areas for expected types of health IT-related sentinel events and provide a means of classifying such events based on literature, experience, and expert opinion; develop and post materials, tools, and resources; and host a webinar to help health care providers identify, report, correct, and avoid health IT-related sentinel events. The Joint Commission will produce a final report describing investigations, identifying resources needed to effectively conduct investigations, describing risk management interventions and corrective actions, and identifying factors that may impact the ability of an external organization to conduct health IT-related investigations. For more information on the ONC contract, visit www.healthit.gov.