2. On today’s call:
Adam Wong
JL Neptune Kathy Kenyon, JD
Management Senior Vice
and Program Senior Policy Analyst
President
Analyst
HHS/ONC
Health 2.0
HHS/ONC
3. Agenda for Today’s Meeting
ONC and the Investing in Innovation (i2)
Program
Reporting Patient Safety Events Challenge
Q&A About the Challenge
5. i2 Goals
• Better Health, Better Care, Better Value through Quality
Improvement
– Further the mission of the Department of Health and Human Services
– Highlight programs, activities, and issues of concern
• Spur Innovation and Highlight Excellence
– Motivate, inspire, and lead
• Community building – Development of ecosystem
• Stimulate private sector investment
6. Why focus on Reporting Adverse Events?
• National Quality Strategy # 1 Priority –
“Making care safer by reducing the harm caused
in the delivery of care.”
• Healthcare related errors continue to account
for a significant amount of harm and death in
the American health care system each year.
– 1 in 3 hospitalizations have adverse events (AEs) that reach patients
– We do not know about AEs in ambulatory settings
7. Most health care organizations
collect AEs, but not very well
• Estimates vary, but a recent study found that
14% of incidents that harmed Medicare
beneficiaries in hospitals were reported.
– Despite the fact that Medicare conditions of
participation require incident reporting in most
health care organizations (although not in
ambulatory practices).
8. AHRQ’s Patient Safety Organizations (PSOs)
Created by the Patient Safety Quality Improvement
Act of 2005 (Patient Safety Act), PSOs
– Allow health care providers to collect and analyze data
without fear of legal discovery
– Must protect the privacy of patients and reporting
organizations.
• Currently there are 75 PSOs listed with AHRQ.
– Sponsors include hospital associations, health systems,
collaborations of health systems (including academic
medical center), national safety organizations and
analytics vendors, liability insurers, professional
associations, and single issue sponsors (e.g. medication
safety, anesthesiology, and blood banks).
9. Common Formats and Reporting
• AHRQ has created the Common Formats (CFs) v 1.2
for AE reporting using structured data, designed for
reporting to multiple sources.
– AHRQ’s PSO Privacy Protection Center hosts CFs and
removes identifiable information to allow data aggregation in
the Network of Patient Safety Databases.
• Providers may also use CFs to send reports to state
agencies and the Food and Drug Administration.
10. Increased reliance on PSOs
• The IOM’s 2011 report Health IT and Patient Safety:
Building Safer Systems for Better Care
recommended voluntary reporting by providers to
PSOs using AHRQ’s Common Formats as “best
option.”
• Under the ACA, by 2014 a hospital that contracts
with a health plan that participates in an insurance
exchange is required to have a patient safety
evaluation system that includes reporting to PSOs.
11. The Challenge
Develop an application that facilitates
the reporting of patient safety events,
whether implemented in hospital or
ambulatory settings.
12. Description: App should . . .
• Increase the ease of reporting patient safety events
to the provider or parent organization;
• Enable providers to import relevant EMR, PHR, and
other electronic information, including screen shots,
to the patient safety report and, in turn, submit an
AHRQ Common Formats-compliant report to one or
more PSOs;
• Capture useful demographic and other relevant
information from each patient including age, gender,
race, and relevant diagnoses;
13. App should . . .(cont’d)
• Capture information about the type of organization
submitting the report using AHRQ's PSO
Information format
• Reduce burden of reporting by enabling the option
of submitting information in the patient safety report
to public health or health oversight organizations,
including state or federal programs or accrediting or
certifying bodies.
• Be platform-agnostic;
• Leverage and extend NwHIN standards and
services including, but not limited to, transport
(Direct, web services), content (Transitions of Care,
CCD/CCR), and standardized vocabularies.
14. Resources
• Information on PSOs and Common Formats is
available at http://www.pso.ahrq.gov/
• The Common Formats v 1.2 is available on the
PSO Privacy Protection Center website at
https://www.psoppc.org/web/patientsafety
15. Judging Criteria
1. Effectiveness of the system in facilitating patient
safety event reporting including its compliance
with AHRQ’s Common Formats
2. Usability and design from the standpoint of all
stakeholders
3. Ability to integrate with electronic health records
and other HIT data sources
4. Creativity and innovation
5. Leverage NwHIN standards including transport,
content, and vocabularies
16. Timeline
• Submission period begins: June,
2012
• Submission period ends: August 31, 2012
• Winners announced: September, 2012
