David R. Hunt, MD, FACS Chief Medical Officer and Acting Director, OHITA Office of the National Coordinator for HIT Health IT and Patient Safety: ONC Context

Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous. The role and education of doctors in the delivery of healthcare. Hollister Lecture delivered at the Institute of Health Services Research, Northwestern University, Illinois, USA. October Lancet 1999;353:1178–81. Sir Cyril Chantler

“As to diseases make a habit of two things - to help, or at least, to do no harm.” Epidemics I Hippocrates :

4 Quality = Help Safety = Do no harm

5 Quality Healthcare Effective Patient-Centered Timely Equitable Safe Efficient

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7 Solo 6% EHR Adoption by Practice Size DesRoches, V, et. al.; Electronic Health Records in Ambulatory Care — A National Survey of Physicians N Engl J Med July 2008;359: % Physicians* Percentage of physicians With notes, Rx orders, & ability to order and obtain lab results Dual 9% 3-5 physicians 22% >10 physicians 35% 6-10 physicians 28%

8 Capacity to select contract, install, implement Transition productivity loss Concerns about system obsolescence Finding an EHR to meet needs Uncertainty of return on investment (ROI) Amount of capital needed Major Barriers to Adoption of Electronic Health Records DesRoches, V, et. al.; Electronic Health Records in Ambulatory Care — A National Survey of Physicians N Engl J Med July 2008;359:50-60.

“…reckoning that all such matters should be kept secret…” Hippocratic Oath

10 Principles, Policies, Procedures, Protections Privacy

Federal Register/ Vol. 74, No. 101/ Thursday, May 28, 2009/ Notices

12 54% Finding an EHR to meet needs 44% Concerns of obsolescence 39% Capacity to implement SEC HEALTH INFORMATION TECHNOLOGY IMPLEMENTATION ASSISTANCE. (a)Health Information Technology Extension Program- To assist health care providers to adopt, implement, and effectively use certified EHR technology that allows for the electronic exchange and use of health information… (c) Health Information Technology Regional Extension Centers- (1) IN GENERAL- The Secretary shall provide assistance for the creation and support of regional centers (in this subsection referred to as `regional centers') to provide technical assistance and disseminate best practices and other information learned from the 41% Transition productivity loss

13 NEW!MEA CULPA Errant mouse click leads To negative laparotomy

14 THE MISTAKE: Three days later, a third check of antibody levels revealed a value of >90% (normal, <3%) pointing to autoimmune hypoglycemia. FIGURE: Normal imaging Despite a normal CT scan, the surgeon reluctantly offered surgical exploration. DISCUSSION: Insulin levels were far too elevated for a usual insulinoma. When faced with a patient with all signs and symptoms of hyperinsulinism, checking insulin, c- peptide, glucose, and sulfonylurea levels is appropriate. However, extreme insulin elevation (typical insulinomas reveal values of 15–90 Iu/mL) suggests another source. Insulin antibody elevations are rare. The treatment is observation and supportive care. It resolves spontaneously. A “systems problem” may explain the surgical team’s failure to preoperatively check insulin antibody levels. The data is only available via electronic medical records (EMR) with a right mouse click. A left click didn’t show anything, so we assumed the value was normal. Mea Culpa. Our institution is now fixing the EMR display feature. THE PATIENT: An 80-year-old woman with classic symptoms of neuroglycopenia underwent a battery of tests confirming the Whipple triad…. NEW!MEA CULPA

15 Hippocrates Decorum 11 You better know what you should do before you enter, for in many cases help is needed, not thought.