in addressing this urgent need to better understand risks and benefits associated with health IT, as well as strategies for improvement and remediation. As it stands now, there is a lack of accountability on the part of vendors, who are generally perceived to shift responsibility and accountability to users through specific contract language (Goodman et al., 2010). As a result, the committee believes a number of critical gaps in knowledge need to be addressed immediately, including the lack of comprehensive mechanisms for identifying patient safety risks, measuring health IT safety, ensuring safe implementation, and educating and training users.

Developing a System for Identifying Patient Safety Risks

The committee believes that transparency, characterized by developing, identifying, and sharing evidence on risks to patient safety, is essential to a properly functioning market where users would have the ability to choose a product that best suits their needs and the needs of their patients. However, the committee found sparse evidence pertaining to the volume and types of patient safety risks related to health IT. Indeed, the number of errors reported both anecdotally and in the published literature was lower than the committee anticipated. This led primarily to the sense that potentially harmful situations and adverse events caused by IT were often not recognized and, even when they were recognized, usually not reported. This lack of reported instances of harm is consistent with other areas of patient safety, including paper-based patient records and other manually based care systems, where there is ample evidence that most adverse events are never reported, even when there are robust programs encouraging health professionals to do so (Classen et al., 2011; Cullen et al., 1995).

Information technology can assist organizations in identifying, troubleshooting, and handling health IT-related adverse events. Digital forensic tools (e.g., centralized logging, regular system backups) can be used to record data during system use. After an adverse event occurs, recorded data—such as log-in information, keystrokes, and how information is transported throughout the network—can be used to identify, reconstruct, and understand in detail how an adverse event occurred (NIST, 2006).

Because of the diversity of health IT products and their differing effects on various clinical environments, it is essential that users share detailed information with other users, researchers, and the vendor once information regarding adverse events is identified. Examples of such information include screenshots or descriptions of potentially unsafe processes that could help illustrate how a health IT product threatened patient safety. However, as discussed in Chapter 2, users may fear that sharing this information may violate nondisclosure clauses and vendors’ intellectual property, exposing them to liability and litigation. Although there is little evidence on the



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