(upbeat music)
-: Hello and welcome to Take Five with the Joint Commission.
I'm John DePaolis and I'll be your host for this episode.
Today we're beginning our multi-episode celebration
of the 2021 John M. Eisenberg
Patient Safety and Quality Award recipients.
These awards recognize major achievements
to improve patient safety and healthcare quality.
There are three recipients each year.
They go to an individual,
an organization impacting quality care
at the national level,
and an organization impacting quality care
at the local level.
In this episode, we're going to talk with Dr. Hardeep Singh,
who received an Eisenberg Award
for his individual achievements
in promoting patient safety and high-quality care.
Dr. Singh is a Professor of Medicine
and chief of the health policy,
quality and informatics program,
Center for Innovations in Quality, Effectiveness and Safety
at the Michael E. DeBakey VA Medical Center
and Baylor College of Medicine.
Dr. Singh has made seminal contributions
in patient safety research,
including the creation of several diagnostic
and health IT safety tools
that are in use throughout the United States.
He also has conducted foundational research on defining
and measuring diagnostic error
and developed national Veterans Affairs policy
with tools and checklists
for safely communicating test results
to patients and providers.
His work has influenced initiatives
and policy work from numerous stakeholders,
including CMS, the Department of Veterans Affairs,
the National Quality Forum and the Joint Commission,
just to name a few.
Dr. Singh, thank you so much for coming on the show today
to discuss your work.
-: Well, thank you for having me on.
-: To start, can you tell me a little bit
about the E-trigger tools that identify missed opportunities
in the diagnostic process
and how you went about implementing those
into the electronic health record?
-: Sure, so the inspiration behind those
electronic trigger tools were
we were losing test results to follow up.
So there were patients who had abnormal test results,
abnormal chest x-rays, abnormal lab tests,
who didn't get any follow up
despite having been seen in a system
with electronic health records.
So we thought could our electronic health record system
help us track and catch these patients
before their diagnosis gets delayed.
So essentially it was like pulling in needles
from a haystack by making a haystack smaller
and using a magnet to pull out those needles
from this electronic health record data warehouse.
So we developed these trigger tools
so that we could flag just the patients
out of these huge data sets,
patients that were having possible loss to follow up issues.
And we implemented these trigger tools and systems
that would be using, for instance,
electronic health records,
which would then enable somebody from the system
to act upon the patient's sort of,
if their record gets flagged
then call the patients back for follow up.
And what we've been trying to do is,
there are different types of trigger tools.
One is for trying to prevent those missed follow ups,
like the ones I mentioned,
but we've also developed trigger tools
that identify patients who might be having
a missed and delayed diagnosis.
So if I show up in an emergency room
and then a week later I got unexpectedly
admitted to the hospital,
we often do a look back to see,
was there a missed opportunity in diagnosis
at that first emergency room visit?
So we've developed these algorithms
that can help identify patients
who may have had these unexpected visits back
and then got admitted
from the electronic health record data.
We review these patients to see
were there any missed opportunities?
So essentially what I'm trying to do here
is to try to use electronic health record data
to identify patients
either before they have a potential diagnostic harm
or after they've had one
so that we can learn and figure out how to do better.
And now we're working with different health systems
to try to enable the use of these electronic trigger tools
so we can identify these patients ahead of time.
-: This is fascinating.
Can you tell me a little bit more about your work
on improving diagnostic safety
that you did with the agency
for healthcare research and quality?
-: Sure, so some of the work that we've done in research
is now getting translated to practice improvement
and that's sort of the work we've been doing recently.
Now, of course, AHRQ has funded a lot
of our research in diagnostic safety for years.
In fact, some of the electronic trigger tools
that we developed were also developed
from either Department of Veterans Affairs
collaboration and funding, or AHRQ funding.
But what we've been doing recently with AHRQ
is really exciting because what we are doing is
using scientific evidence, using best practices
that have already been established in the field
and make them into more actionable items for health systems.
So, I was giving you an example
of how health systems could build these,
sort of these track and catch mechanisms
to get patient safety data out of the EHR,
or to figure out, let's say, if they wanna learn
from patients or patient complaints,
or they wanna learn from clinician reports,
or looking at their data for where the opportunities are,
where the missed opportunities are.
How does a health system actually do that?
I mean, it's easy for researchers like me to say,
"Hey, we wrote a cool paper on this electronic trigger,"
or, "We wrote a cool paper on measurement strategies
"that health systems can use,"
but what health systems want to know is,
tell us how to do it,
tell us to practically implement this evidence
in our daily, day-to-day operations
and that's what we are doing with AHRQ now.
So we're building tools.
One of them is for the health system
which is called Measure DX.
It should be coming out sometime in June this month of 2022,
and this would be a resource for health systems.
We're also building tools for clinicians
because we think that if clinicians can get feedback
on their performance related diagnosis, they will do better.
One of the problems we have in healthcare is,
as a clinician, I never find out what happens
to my patients all the time, right?
So we don't have good closed-loop feedback systems
that can let us know what happened to our patients
after I saw them, like, let's say,
a month or two or three months later.
So what we are doing is we're trying to develop strategies
that clinicians can use to do some type of a self-audit.
That means select some medical records to look at,
to learn from them and do it in a systematic fashion
and that tool is called Calibrate DX,
because it helps you calibrate yourself through feedback
and we are building this tool now
and this tool should be available in about three months,
about September of 2022, hopefully a bit earlier than that,
and that is also being done with AHRQ collaboration.
So one tool, Measure DX for health systems,
how to measure diagnostic safety in your organization.
And the second is Calibrate DX for clinicians.
How do you learn, how do you self improve
by looking at your own performance?
So hopefully both of those will be useful for the field.
-: Definitely, now, how did you develop
the eight-dimension sociotechnical model
for studying health IT
and can you explain a little bit about how it works?
-: Sure, so this model was developed in collaboration
with my close colleague, friend
and partner in crime, Dean Sittig.
So Dean Sittig moved to Houston about 14 years ago or so
and we started chatting about all the research
that I was trying to do in the EHR.
So I thought initially, technology's gonna solve
a lot of the problems
related to missed and delayed diagnosis
because it can help us communicate better,
it can help coordination, and I just wasn't finding that.
So I was finding referrals that were lost to follow up.
I was finding test results that were lost to follow up.
A team has been documenting electronic health record
related issues related to patient safety for a while
and I'm thinking we're not achieving the potential
of electronic health records.
And then, while we were discussing all these factors,
both Dean and I started realizing
that there is obviously those technology related factors,
so the software, the user interface,
usability of the system, the hardware,
the content in the computer or the electronic health record.
But a lot of times there's these organizational factors,
or person factors, or workflow factors,
culture, leadership, policies and procedures,
external rules and regulations
that influence the way we practice,
that make a difference on how we are doing
in terms of safety.
So if I have a rule or a policy that affects
the way I deliver healthcare or the way I practice medicine
and if it's adversely affecting the way,
just think about it, documentation requirements.
So we are so busy documenting things
in the electronic health record
that we often forget the big picture,
we lose our situational awareness
and so we started thinking,
let's get a list of all the factors
that are potentially affecting patient safety
in the context of the electronic health record.
Why are we not getting the best outcomes
from our electronic health records?
And so Dean was bringing in this concept of
technology has to be safe because he had seen a lot
of bugs and glitches and software problems.
I was bringing in this concept of use of technology,
where we had a fantastic electronic health record system
but we were not using it to achieve the full potential.
And now what I described earlier on was using technology
and using data and information
to help patient safety
which is sort of what our end goal was, right?
That's why we implemented electronic health records.
So if you put all these things together,
we want to have safe technology, safe use of technology,
and use technology to improve patient safety.
We have to do all three and if you have to do all three,
then you have to use a sociotechnical approach
in order to do that and what we mean by that
is essentially think about not just the technical things
that we talked about, software, hardware,
content, user interface,
but also think about all the non-technical things,
such as workflow, organizational factors, culture,
training, people, rules and regulations,
because all of that makes a difference
in how we are performing in healthcare
and when we put those two things together
and A-dimensional model came up where we suggested
that all eight of those dimensions have to be addressed
in order to improve patient safety
in the context of electronic health record.
And the way we've applied this model now,
which has now been used for the last 12 years or so.
In fact, it is one of our highly cited papers.
It is one that is being very often used
in sort of the conversation
to frame a sociotechnical approach to healthcare.
We've used it in many studies and it helps us think through
some of the factors and individually improve upon
those factors as interventions.
So you gotta be thinking about all of these things
if you want to improve healthcare.
So it's been really useful to our research work
because it's given us a lens to use
when we look at our study findings
or when we develop study findings,
or we develop a study, it has proven to be extremely useful
for us over the last decade or so.
-: Now I've also heard a little bit about the SAFER Guides
you've developed with the Office of National Coordinator
for Health Information Technology.
How do those help hospitals perform
safety assessments of their EHRs?
-: Sure, so the SAFER Guides have been
really one of our biggest achievements.
In fact, this was also work that I did
with my colleague Dean Sittig,
where we looked at what were the things
that health systems could do
to improve the implementation and use
of the electronic health record system.
And we looked at that from the safety perspective.
So the SAFER Guides are essentially checklist like items,
so there are nine guides, they all have some best practices,
anywhere from 11 to, I believe, 21 or 22 in each of those.
So there's total of 147 practices
that we recommended across the nine guides.
What the guides help the health system do
is to do a proactive risk assessment
of how you have implemented your electronic health record
and if you've done it safely or not.
Are you using it correctly or not?
We've got some technical areas in SAFER Guides,
such as downtime, such as configuration of your EHR,
but we've also have some clinical areas,
such as patient notification or communication,
patient order entry, so order entry through the computer
of how you order medications or tests.
So we have all these areas that we focus on
through SAFER Guides and this compendium
is supposed to be used sort of together
and we envisioned that multidisciplinary teams
at every health system would be able to use SAFER Guides
to do a self-assessment and then figure out
what are the practices that they need to implement?
Which ones are they doing?
Which ones are they not doing?
And which ones are they doing partially?
Because the ones you're doing, great.
But if you're not doing some practices
or if you're doing them only partially,
what this multidisciplinary team
at the health system level needs to ask themselves is,
should this health system be doing this best practice
in terms of using it safely?
And so initially there was not a lot of uptake we found.
A few hospitals did these guides but what happened last year
which was really a landmark event for us,
is CMS made these guides a requirement
for all eligible hospitals in the U.S.
These are freely available guides,
available on healthit.gov.
If you just Google ONC SAFER Guides
you can actually get all of them freely
and what this is gonna help hospitals and health systems do
is get that multidisciplinary team together,
do an assessment using these guides, just like checklist.
You know, are we doing this? Are we not doing this?
And then figure out, based on what you are finding,
what's your next step?
What are you gonna do to improve
the use of the electronic health record
or make sure you're not losing test results
or make sure you order entry is taken care of
or make sure you're following downtime procedures.
All of these things could be developed, implemented better,
as long as hospitals can do the SAFER Guides.
Now again, some of these require
a multidisciplinary approach,
that means you need to have multiple people on the table.
So it's just not the medical informatics officer problem,
it's also quality and safety needs to work with informatics
to do some of this work,
we need to have clinicians onboard,
we need to have some IT and the vendors also onboard
for some of these, in fact some of the vendors
have taken up our recommendations.
They are using SAFER Guides as well to figure out,
is their product able to meet SAFER Guide requirements.
So we really think this could be, in the next five years,
a very useful tool for all health systems to use
at their enterprise level
to make sure that they are really doing a good job
of implementing their electronic health records safely.
So I'm really excited about it.
-: You know, with all you've already accomplished,
I'm curious, what's next?
-: Oh, thank you, you know I often think,
how long am I gonna keep doing research
and publishing papers?
I still enjoy that.
I still enjoy the research part of producing evidence,
producing some tools that could be useful
for health systems, checklists.
But I think now, in the next five years,
it's gonna be about scaling and impact.
We've produced enough research knowledge now
that could be useful for health systems,
ambulatory care organizations, clinicians, patients,
I think my next step, and this is what I think
I wanna focus on in the next five years,
is how do we now scale?
How do we make an impact?
We've got the tools, we've got the evidence,
we've got the best practices,
how do we close the implementation gap?
So that's my strategy over the next few years is gonna be
how do we close the implementation gap and scale our reach.
And we want to be able to reach all health systems,
not just in U.S.,
but across the world with some of our findings.
This is not a U.S. problem.
This is not a local problem.
This is not a one health system problem.
This is a global problem.
Missed and delayed diagnosis and use of technology,
sort of the two areas that I study,
are global problems that need to be sort of rectified.
So we're thinking about how we try to go
from trying to do just research and produce some papers
and produce some tools to making an impact,
using those tools, working with different health systems,
to try to adopt those tools,
because remember, we can build these tools.
We can build these best practices.
In fact, we have many tools over time for test results,
for referrals, and in fact, you mentioned some of them
but how do we get them adopted, right?
How do we get health systems to use them?
I mean, we can appeal to the intrinsic motivation
of clinicians and health systems to do the right thing
but some of you have sort of felt this
as a patient safety researcher
and a person who's trying to improve patient safety.
I often get asked, what's your business case?
What's your ROI?
Well, I don't have a lot of business case
except for the fact that I'm trying to prevent harm.
And so we can appeal to the intrinsic motivation
of health systems to make sure they use these tools,
these best practices to implement evidence into practice,
but we're also gonna need some extrinsic motivators
to help push us along.
So I'm also wanting to try to work with policy makers
who can make that change.
Who can get these tools adopted
because health systems often tend to do the things
only that are required by somebody,
such as an accrediting organization, or (indistinct),
or some kind of policymaker or some kind of regulation.
And somehow we need to do both.
We need to do the intrinsic motivation saying,
"Here, we have to reduce harm and this is appealing,"
but we also have to work with policymakers
to make sure that there's extrinsic pressure
in terms of incentives and making sure
that we are having the, quote unquote,
the business case to do the right thing,
which is really preventing harm to patients.
-: If people want to keep up with what you're doing now,
where can listeners go to learn more about your work?
-: Sure, so I often put things out on Twitter,
please follow me, it's @HardeepSingh,
at H-A-R-D-E-E-P-S-I-N-G-H-M-D,
so it's @HardeepSinghMD.
I am on LinkedIn as well. Please connect with me.
I often put in my new articles
and some other items on LinkedIn.
PubMed is always good which is,
you find my articles, but you have to put Houston
because there's a lot of Singhs out there,
so you should put Hardeep Singh Houston.
But I also have a website, both a VA and a Baylor website
that gives you information about my work.
So if you just Google my name, Hardeep Singh MD, Houston,
or Baylor or VA, you'll find me.
Very easy to keep track of me these days
and also I like to put my papers and findings out there
so hoping that some people would read it
and would get inspired to do change and improvement
in their organization or their clinic
and find some of the work that I do useful.
So please connect with me and keep in touch, thank you.
-: Dr. Singh, thank you so much for coming on the show today
to talk about the interesting work you've done.
-: Thank you for having me on
and it was a pleasure to talk to you.
-: And as always, thank you all for listening.
You can find more episodes of this program
on the Joint Commission's website
at www.jointcommission.org.
This has been Take Five With the Joint Commission.
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