Dearth of Data Drove Reform Plan

The "eye-opening" realization that the health IT world shares little information about failures that threaten patient safety prompted a federal study group's recommendations to make more information public, according to the group's chair.

Gail L. Warden chaired the Institute of Medicine's patient safety and health IT committee, which this week released a report calling for federal oversight of health IT. The report, "Health IT and Patient Safety: Building Safer Systems for Better Care," was commissioned by the Office of the National Coordinator for Health IT, part of the Department of Health and Human Services.

The committee recommended creating an organization similar to the National Transportation Safety Board to investigate safety failures, publicly share lessons learned and recommend fixes. It decried nondisclosure clauses in health IT vendor contracts and called for mandatory disclosure of errors that compromise patient safety.

The "current state of safety of health IT must not be permitted to continue," Warden wrote in a preface to the report.

"We tried to balance the findings in the literature with anecdotes from the field but came to the realization that the information needed for an objective analysis and assessment of the safety of health IT and its use was not available," Warden wrote. "This realization was eye-opening and drove the committee to consider ways to make information about the magnitude of the harm discoverable."

He described the report as offering a "vision for how the discipline of safety science can be better integrated into a health IT-enabled world."

Government needs to be part of the solution, Warden wrote, in part because of the billions it is investing to help medical providers buy and implement expensive electronic health records and other health IT systems.

Warden, president emeritus of the Henry Ford Health System, in Detroit, emphasized the committee's belief that its recommendations can improve patient safety without constraining innovation.

The Institute of Medicine is part of the National Academy of Science. The health IT report is available for purchase through the institute, but also is available for free reading or download through its website.