Appendixes



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Patient Safety: Achieving a New Standard for Care Appendixes

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Patient Safety: Achieving a New Standard for Care This page intentionally left blank.

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Patient Safety: Achieving a New Standard for Care A Biographies of Committee Members Paul C. Tang, M.D., M.S., Chair, is Chief Medical Information Officer at the Palo Alto Medical Foundation and Associate Clinical Professor at the University of California, San Francisco. He received his B.S. and M.S. in Electrical Engineering from Stanford University and his M.D. from the University of California, San Francisco. He is a practicing, board-certified physician in Internal Medicine. His responsibilities include implementing an electronic medical record system and directing an eHealth initiative. His research interests include medical informatics, computer-based patient record systems, clinical decision support, and Internet-based health care services. Previously, Dr. Tang was Medical Director of Information Systems at Northwestern Memorial Hospital and Associate Professor of Medicine at Northwestern University Medical School. Dr. Tang has served on several Institute of Medicine (IOM) committees and is currently a member of the IOM Health Care Services Board. He is a Fellow of the American College of Medical Infomatics, the American College of Physicians, the College of Healthcare Information Management Executives, and the Healthcare Information and Management Systems Society. He is Past Chair of the Computer-based Patient Record Institute and serves on the Board of Directors of the American Medical Informatics Association. Molly Joel Coye, M.D., M.P.H., Vice-Chair, is the Founder and Chief Executive Officer of the Health Technology Center, a nonprofit organization dedicated to advancing the use of beneficial technologies for healthier

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Patient Safety: Achieving a New Standard for Care people and communities. Until 2000, Dr. Coye was the director of the west coast office for The Lewin Group, a leader in health care policy, strategic planning, and management consulting. She previously directed product development for HealthDesk Corporation, a developer of consumer software for interactive health communication and disease management and was Executive Vice President for Managed Care in the Good Samaritan Health System, a nonprofit integrated health care system and the largest provider system in the Santa Clara Valley. From 1991 to 1993, Dr. Coye was the Director of the California Department of Health Services, managing a budget of more than $16 billion, 5,000 employees, and 160 branch and field offices throughout the state. Dr. Coye also directed the Division of Public Health at the Johns Hopkins School of Hygiene and Public Health and served as Commissioner of Health for the State of New Jersey from 1986 to 1990. Dr. Coye is a member of the Institute of Medicine, was a member of the IOM Committee on the Quality of Healthcare in America, and chaired the IOM Committee on Access to Insurance for Children. A former trustee of The California Endowment and the China Medical Board, Dr. Coye is currently a member of the Board of Trustees of the Program for Appropriate Technology in Health (PATH). She received her M.D. and M.P.H. from Johns Hopkins University. Suzanne Bakken, R.N., D.N.Sc., F.A.A.N., is Alumni Professor of Nursing and Professor of Biomedical Informatics at Columbia University. She received her B.S.N. from Arizona State University in 1974; her M.S. in Critical Care from the University of California, San Francisco (UCSF) in 1980; and her D.N.Sc. in Nursing Informatics from UCSF in 1989. She was a Post-Doctoral Fellow in Medical Informatics at Stanford University. Her primary professional interests are evidence-based advanced practice nursing, medical informatics, and HIV/AIDS. Dr. Bakken is a Fellow for both the American Academy of Nursing and the American College of Medical Informatics. She has worked actively in the area of data standards for the past decade. previously serving as the American Nurses Association Liaison to Health Level 7 and Chair of the Convergent Terminology Group for Nursing of the SNOMED International Editorial Board. She is currently a member of the Clinical LOINC Committee and leads the work item task force for an International Standards Organization standard for a reference terminology model for nursing. E. Andrew Balas, M.D., Ph.D., is the Director of the Center for Health Care Quality, a health policy think tank at the University of Missouri. He

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Patient Safety: Achieving a New Standard for Care also serves as the Director of the European Union Center of Missouri, a multidisciplinary initiative to explore the policy implications of emerging new technologies. He holds the Thomas P. Weil Distinguished Professorship at the Department of Health Management and Informatics, School of Medicine, University of Missouri. He received his M.D. in 1977 from Semmelweis University School of Medicine, his M.S. in Applied Mathematics from Eotvos University of Science in 1983, and his Ph.D. in Medical Informatics from the University of Utah School of Medicine. Dr. Balas, as a Congressional Health Policy Fellow, worked for the Public Health Subcommittee of the U.S. Senate. He has also served on several review panels of the National Institutes of Health and the Agency for Health Care Research and Quality. He is an elected Fellow of the American College of Medical Informatics. In addition, Dr. Balas served on the Quality of Health Care in America Technical Panel 3: Using Information Technology to Improve Quality in Health Care. David W. Bates, M.D., M.Sc., is Chief of the Division of Internal Medicine at the Brigham and Women’s Hospital in Boston and Associate Professor at Harvard Medical School. He is also the Medical Director of Clinical and Quality Analysis for Partner’s Healthcare Systems, where he evaluates the impact of information systems across the Partner’s network. Dr. Bates’s primary interest has been the use of computer systems to improve care, and he has conducted extensive work on evaluating the incidence and preventability of adverse drug events. At the national level, Dr. Bates is one of two science advisors to the SCRIPT project, which is charged with developing medication indicators that may be adopted by the Centers for Medicare & Medicaid Services. In addition, he serves as an advisor to the Leapfrog Group and is the editor of Journal of Clinical Outcomes Management. Dr. Bates received his M.D. from Johns Hopkins University School of Medicine in 1983 and his M.Sc. from the Harvard School of Public Health in 1990. He is a practicing, board-certified physician in Internal Medicine. John R. Clarke, M.D., is a Professor of Surgery at Drexel University, an Adjunct Professor of Computer and Information Science at the University of Pennsylvania, and an Adjunct Senior Fellow of the Leonard Davis Institute of Health Economics. Dr. Clarke is a member of several regional, national, and international professional societies, including the American Association for Artificial Intelligence, the American Medical Informatics Association, and the Society for Medical Decision Making. He is a Governor of the American College of Surgeons. He has been involved in many

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Patient Safety: Achieving a New Standard for Care activities involving patient safety. He has also conducted research in the area of medical errors using large databases and computer-based decision support. He has published extensively in the areas of clinical decision making. He received his B.A. from Wesleyan University in 1965 and his M.D. from the University of Pennsylvania in 1968. David C. Classen, M.D., M.S., is a Vice President at First Consulting Group (FCG) and leads FCG’s quality of health care initiatives consulting practice in this area. Dr. Classen is also an Associate Professor of Medicine at the University of Utah and a Consultant in Infectious Diseases at the University of Utah School of Medicine. Previously, he served as Chief Medical Resident at the University of Connecticut and was the chair of Intermountain Health Care’s Clinical Quality Committee for Drug Use and Evaluation. He received his M.D. from the University of Virginia School of Medicine and his M.S. in Medical Informatics from the University of Utah School of Medicine. Dr. Classen’s research interests are in the computer applications of epidemiologic techniques to investigate clinical outcomes. He is also involved in the development of expert system technologies to provide decision support in the monitoring and prescribing of medications. Dr. Classen has lectured and consulted, nationally and internationally, on clinical process improvement, computer-assisted decision support, and information system technology in health care. He is the author and coauthor of numerous scientific publications and book chapters on the use of decision support and epidemiologic techniques to improve the use and safety of medications. Simon P. Cohn, M.D., M.P.H., is the National Director of Health Information Policy for the Kaiser Permanente Medical Care Program, Oakland, California. He has been a leader in Kaiser Permanente’s efforts to develop comprehensive health information systems to support both the delivery of health care and health research. Dr. Cohn is a nationally recognized expert on issues related to HIPAA Administrative Simplification, health care data management, clinical classifications, and electronic transmission of health care data. He is a member of the National Committee on Vital and Health Statistics and chairs its Subcommittee on Standards and Security. He is also a member of the National Uniform Claims Committee and the AMA CPT Editorial Panel. Dr. Cohn is board certified in Emergency Medicine and continues an active clinical practice. He is a Fellow of the American College of Emergency Physicians and American College of Medical Informatics.

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Patient Safety: Achieving a New Standard for Care Carol Cronin, M.S.W., M.S.G., is currently serving as a Senior Technical Advisor to the Delmarva Foundation, where she is assisting with hospital performance public reporting. In addition, she has worked as an independent consultant on consumer health information and Medicare to a number of foundations and nonprofits, including the Atlantic Philanthropies, AARP, the Markle Foundation, the National Health Council, and the Robert Wood Johnson Foundation. Previously, she served as the first Director of the Center for Beneficiary Services at the Health Care Financing Administration (HCFA; now the Centers for Medicare & Medicaid Services), where she was responsible for planning, implementing, and evaluating the National Medicare Education Program (NMEP) from 1998 to 2000. She also served as chief HCFA spokesperson on beneficiary issues to the media, Congress, and national aging, consumer, and health industry organizations. From 1984 to 1994, she worked in leadership positions in Washington, DC, for the employer-based Washington Business Group on Health and the Managed Health Care Association on issues related to health outcomes measurement, accreditation, and consumer satisfaction. She holds an A.B. from Smith College and a Master’s of Social Work and Master’s of Gerontology from the University of Southern California. Jonathan S. Einbinder, M.D., M.P.H., is Corporate Manager for Quality Data Management in the Clinical Informatics Research & Development group at Partners HealthCare System. He is responsible for facilitating the use of information systems for quality measurement and improvement at Partners. He also has appointments at Harvard Medical School and in the Department of Medicine at Brigham and Women’s Hospital, where he practices as a general internist. Dr. Einbinder is a graduate of the Columbia University College of Physicians & Surgeons. After residency training in Internal Medicine at Brigham and Women’s Hospital and Harvard Community Health Plan, he completed fellowships in Clinical Computing and General Medicine at Beth Israel Deaconess Medical Center, receiving an M.P.H. from the Harvard School of Public Health. Prior to joining Partners, Dr. Einbinder was Assistant Professor in the Department of Health Evaluation Sciences at the University of Virginia, where he directed the Clinical Data Repository project and taught in the department’s M.S. degree program. Larry D. Grandia, M.E., is currently Chief Technology Officer and Executive Vice President for Premier, Inc., in San Diego. His responsibilities include fee-for-service areas such as performance services, comparative data and decision support, benchmarking, information technology consulting,

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Patient Safety: Achieving a New Standard for Care and Premier’s internal information technology management systems. Prior to joining Premier in 2000, Mr. Grandia was President and Chief Executive Officer of DAOU Systems, Inc., a publicly traded health care information technology (IT) professional services company. Before that, he led IT functions for Intermountain Health Care, Inc., a leading not-for-profit health care system based in Salt Lake City, for more than two decades. He has also held positions at IBM and at a regional health care management engineering and consulting firm. He is a frequent health care industry speaker and has been active in industrywide professional groups. Mr. Grandia earned a Master’s in Engineering Administration, with honors, at the University of Utah following an undergraduate degree in general engineering and industrial management at the University of Wyoming. W. Ed Hammond, Ph.D., is Professor Emeritus in the Departments of Community and Family Medicine and Biomedical Engineering at Duke University. Dr. Hammond shares responsibility for the medical informatics courses taught at the Duke University medical center and for graduate studies in medical informatics in the Department of Biomedical Engineering. Dr. Hammond brings to the program a unique combination of engineering, computer science, administration, education, and medical background. He is experienced in networking (hardware and software), in databases and database design, in programming languages, in decision support, and in the computer-based medical record. Dr. Hammond has taught courses and given tutorials in these areas for many years. For nearly 30 years, he has been developing the internationally known computer-based medical record system, The Medical Record (TMR). Dr. Hammond’s research has focused on producing medical informatics products that can be used in the real world. He has been a member of the Board of Directors of the American Medical Informatics Association and now serves as Treasurer of that organization; he has served twice as Chairman of the Health Level 7 standards group; he is immediate past president of the American College of Medical Informatics; and he is a former chair of the Association for Computing Machinery’s Special Interest Group on Biological Engineering. Past activities include participation in the Summit Task Force for restructuring the aims and goals of the American Medical Record Association and coleader of a workshop on Current Topics in Medical Informatics. He is a member of the International Medical Informatics Association’s Working Group 10 on Hospital Information Systems.

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Patient Safety: Achieving a New Standard for Care Brent C. James, M.D., M.Stat., is the Vice President for Medical Research and Continuing Medical Education and Executive Director of the Institute for Health Care Delivery Research at Intermountain Health Care, Inc., which is widely recognized for its work in clinical quality improvement and electronic clinical decision support systems. He received his M.D. in 1978 and his M.Stat. in Biostatistics in 1984 from the University of Utah. He currently holds Adjunct Professorships in the University of Utah’s Department of Family and Preventive Medicine and Department of Medical Informatics. He is a Visiting Lecturer in the Department of Health Policy and Management at the Harvard School of Public Health and Adjunct Professor in the School of Public Health at Tulane University. He also sits on the boards of several not-for-profit health care institutions with missions directed at measuring and improving the quality and availability of health care services. Dr. James was a member of the Institute of Medicine’s National Roundtable on Health Care Quality and the Quality of Health Care in America Committee. Kevin B. Johnson, M.D., M.S., is an Associate Professor and Vice Chair of Biomedical Informatics, with a joint appointment in the Department of Pediatrics at Vanderbilt University Medical School. He received his M.D. from Johns Hopkins University School of Medicine and his M.S. in Medical Informatics from Stanford University. He served as a Pediatric Chief Resident at Johns Hopkins. He was a member of the faculty in both Pediatrics and Biomedical Information Sciences at Johns Hopkins until 2002. He is a practicing, board-certified physician in Pediatrics. His research areas are clinical information systems development; the uses of advanced computer technologies, including the World Wide Web, personal digital assistants, and pen-based computers in medicine; and the development of computer-based documentation systems for the point of care. Dr. Johnson is the author of numerous publications and has served on several editorial boards, including the journal of the Ambulatory Pediatrics Association and the Journal of American Informatics Association (JAMIA), for which he is an Assistant Editor. He recently was appointed as the Director of JAMIA’s Student Editorial Board. He has been an active participant in the informatics efforts of many national organizations, including the American Medical Informatics Association; the American Board of Pediatrics; the Medical Informatics Special Interest Group of the Ambulatory Pediatrics Association, which he chairs; the American Academy of Pediatrics National Electronic Medical

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Patient Safety: Achieving a New Standard for Care Record Committee, which he chaired; and the Steering Committee on Clinical Information Technologies, which he cochairs. Jill Rosenthal, M.P.H., is a program manager at the National Academy for State Health Policy (NASHP). Ms. Rosenthal provides policy analysis and technical assistance in emerging state health policy issues, focusing primarily on patient safety. Other issues she has addressed include the Children’s Health Insurance Program (CHIP), health disparities, and health care cost containment. While at NASHP she has coauthored a series of reports that focus primarily on state initiatives to address medical errors and patient safety. She has 12 years of experience in public health and health planning, primarily in the areas of health promotion and health policy development, analysis, and advocacy. Prior to joining NASHP, Ms. Rosenthal spent 8 years in West Virginia as Program Manager for the West Virginia Center for Rural Health Development and as Field Director for the West Virginia Bureau for Public Health’s Tobacco Control Program. Ms. Rosenthal earned a Bachelor’s in Psychology from Colgate University and a Master’s in Public Health from the University of North Carolina, Chapel Hill. Tjerk W. van der Schaaf, Ph.D., has been a staff member of the Department of Technology Management at the Eindhoven University of Technology in the Netherlands since 1985. He is currently serving as an Associate Professor of Human Factors in Risk Control and as the coordinator of the Eindhoven Safety Management Group. His main research areas are human behavior (errors and error recovery) and industrial safety, based on organizational learning from (reported) incidents and near misses. Transfer of these experiences in industry and transportation to the medical domain is a major focus, with patient safety projects in the United States, United Kingdom, and the Netherlands. He has coauthored several papers on medical event reporting with James Battles, who is currently a Senior Service Fellow at the Agency for Healthcare Research and Quality, Center for Quality Improvement & Patient Safety. Dr. van der Schaaf received his Ph.D. in 1992 from the Eindhoven University of Technology in safety management based on near-miss reporting in the chemical process industry.