Rev HIT Dublin BChaiken 112009 - HISI Workshop Revolutionary... · Revolutionary Health IT: Path...
Transcript of Rev HIT Dublin BChaiken 112009 - HISI Workshop Revolutionary... · Revolutionary Health IT: Path...
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
1© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
Barry P. Chaiken, MD, MPH, FHIMSSChief Medical OfficerDocsNetwork, Ltd.
© 2009 DocsNetwork, Ltd. 1
Overview
Are We Receiving Value?L t’ M Fi t Let’s Measure First Clinical Information Technology Clinician Adoption Innovation and Transformation Revolutionary HITy
2© 2009 DocsNetwork, Ltd.
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
2© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
“” A crisis is a terrible thing to waste.”
- Paul Romer, EconomistGraduate School of Business
Stanford University
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Spending as Percent of GDP
Source: California Healthcare Foundation, Snapshot Health Care Costs 101, 2009
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Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
3© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
International Comparison of Spending on Health, 1980–2005
$7,000 United StatesGermany
16
Average spending on healthper capita ($US PPP*)
Total expenditures on healthas percent of GDP
$2,000
$3,000
$4,000
$5,000
$6,000CanadaFranceAustraliaUnited Kingdom
6
8
10
12
14
United StatesGerman
$-
$1,000
$2,000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
0
2
4
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
GermanyCanadaFranceAustraliaUnited Kingdom
PPP=Purchasing Power Parity.Data: OECD Health Data 2007, Version 10/2007
5
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
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World’s Highest Spending per Capita
Source: California Healthcare Foundation, Snapshot Health Care Costs 101, 2009
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Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
4© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Medical, Medication, and Lab Errors, Among Sicker Adults
34
402005 2007
Percent reporting medical mistake, medication error, or lab error in past two years
3432
1921 22
2628
30
10
20
30
0
GER NETH UK NZ CAN AUS
International ComparisonData: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
United States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
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Duplicate Medical Tests, Among Sicker Adults
302005 2007
Percent reporting that doctor ordered test that had already been done in past two years
1820
4
89
10
1516
10
20
0
NETH CAN UK NZ AUS GER
International ComparisonData: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
United States
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
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Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
5© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Test Results or Medical Records Not Available at Time of Appointment, Among Sicker Adults
30
Percent reporting test results/records not available at time of appointment in past two years
2005 2007
2322
9
1214
17 1718
10
20
0
NETH GER NZ AUS UK CAN
International Comparison
United States
9© 2009 DocsNetwork, Ltd.
Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
Not So Good
100
120
Amenable Age-Standardized Death Rates per 100,000 (0-74)
0
20
40
60
80
100
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Fran
ce
Japan
Australia
Spain
Italy
Can
ada
Norw
ay
Netherlan
ds
Sweden
Greece
Austria
Germ
any
Finland
New
Zealan
d
Denmark
United Kingdom
Ireland
Portugal
United States
OECD CountriesSource: Nolte E, McKee CM. Measuring The Health of Nations: Updating an Earlier Analysis. Health Affairs Jan./Feb. 2008, P. 58-71.
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
6© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Overview
Are We Receiving Value?L t’ M Fi t Let’s Measure First Clinical Information Technology Clinician Adoption Innovation and Transformation Revolutionary HITy
11© 2009 DocsNetwork, Ltd.
Business Intelligence is Measuring
Market researchD t i i Data mining Epidemiology - healthcare BI Tools and processes similar
– Statistical analysis– Data to information– Easily understood data presentation
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Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
7© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Don’t Measure the Untouchable
Unwanted answers are dangerousFinding what you don’t want to know– Finding what you don’t want to know• Risk of discovering the unpleasant
Measures used must be actionable– Political failure for not acting
Analysis linked to goalsResults lead to wanted change– Results lead to wanted change
– Process in place for change• Governance
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Snapshots, Not Reports
Easily understood informationU f hi t id tif t d Use of graphics to identify trends Utilized for identification of needed focus Applied to monitor progress Permits focus of effort on the important
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Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
8© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Leverage Data Sources
Identify objectives linked to goals– What do we want to accomplish– What do we want to accomplish
Inventory data sources– What data do we have?– Where is our data coming from?– How easily can we use/combine the data?
Develop actionable BI reportp p– Can it be used as a surveillance tool?
Apply process to regularly generate reports– Includes plan for distribution and use
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Creativity Leads to Results
Broad thinking, not silosC ll b ti th th ti ti Collaboration rather than negotiation Experimentation
– Multiple pilot projects
Innovation– Re-inventing– Try new things
© 2009 DocsNetwork, Ltd. 16
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
9© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Overview
Are We Receiving Value?L t’ M Fi t Let’s Measure First Clinical Information Technology Clinician Adoption Innovation and Transformation Revolutionary HITy
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Varied HIT Applications
Physician portalP ti t t l Patient portal Electronic medical record Personal health record
– Google, Microsoft
Health record bank– Electronic, digitized
Regional health information exchange Ancillaries HIT
© 2009 DocsNetwork, Ltd. 18
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
10© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Physician Portal as Information Hub
Source: MedAffinity Corporation 19© 2009 DocsNetwork, Ltd.
Personal Health Records
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Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
11© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Varied Clinical Decision Support
Guidelines, care maps, protocolsO d t ( t t d d ) Order sets (structured orders) Rules-based expert systems
– Intelligent prompting, alerts
Order checking– First Databank for medications
Field edits Relevant, up-to-date patient information Consistent and accessible
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State of CDS
Only 10% of hospitals with adaptable CPOECDS i ifi tl d di l CDS significantly decreases medical errors– Less variation with increased safety
Varied benefits of medication CDS– Usual and maximum doses– Dose adjustment for co-morbidities
P di i d i b d d i h– Pediatric dosing based upon age and weight– Limiting drug dose choices– Evidence-based disease specific order sets
Source: Gross GA, Bates DW. A pragmatic approach to implementing best practices for clinical decision support systems in computerized provider order entry systems. JAMIA;2007;1:25-28.
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Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
12© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Embedded Decision Support
© 2009 DocsNetwork, Ltd. 23
Telestroke Workflow Validation Pilot
Asynchronous telemedicine platform
Image exchange in potential stroke– Image exchange in potential stroke
– First international telestroke network
Mayo Clinic, Phoenix Arizona
Southwestern Ontario hospital
Global health platform
Allowing exchange for clinical case referral– Allowing exchange for clinical case referral
• Between worldwide hospitals
Extra functionalities will be later implemented
© 2009 DocsNetwork, Ltd. 24
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
13© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Information Flow
1. Source Hospital (Canada)
Hospital CT Scan automatically sends Dicom Images to MIO .
Images, Videos, Data > Images, Videos, Data >
© 2009 DocsNetwork, Ltd. 25
3. MEDTINGClinical case web repository. MEDTING stores and indexes uploaded images,
videos and data. MEDTING web interface allows the sender physician to invite the
receiver specialist.
Clinical Case Review/Collaboration
© 2009 DocsNetwork, Ltd. 26
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
14© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Challenges Facing CDS
Clinician adoption– Iteration of improvementsIteration of improvements
Standardization of clinical content Implementation issues
– Non-standard recording of allergies– Difficult to merge allergy lists
• Prior admissions and cross-institutional– Non-drug allergy recordingg gy g– Correcting allergy lists
Alerts and reminders– Too many or too few
Source: Gross GA, Bates DW. A pragmatic approach to implementing best practices for clinical decision support systems in computerized provider order entry systems. JAMIA;2007;1:25-28.
27© 2009 DocsNetwork, Ltd.
Overview
Are We Receiving Value?L t’ M Fi t Let’s Measure First Clinical Information Technology Clinician Adoption Innovation and Transformation Revolutionary HITy
28© 2009 DocsNetwork, Ltd.
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
15© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Stages of EMR Adoption – U.S.
© 2009 DocsNetwork, Ltd. 29Source: HIMSS Analytics, September, 2009.
Physicians’ Use of EMRs
9892 89
100
Percent of primary care physicians using electronic medical records
2001 2006
17
28
79
42
2325
50
75
0
NETH NZ UK AUS GER CAN
International Comparison
United States
Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
© 2009 DocsNetwork, Ltd. 30
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
16© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Secure Clinician Adoption
WorkflowImpact on patient care– Impact on patient care• Quality• Cost
– Efficiency - time• Obtain information• Patient encounter
R d fi di• Record findings
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Who Should Drive Adoption?
Source: Sarah W. Fraser, IHI Forum, December 2002 (Rogers, 1995)
32© 2009 DocsNetwork, Ltd.
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
17© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Overview
Are We Receiving Value?L t’ M Fi t Let’s Measure First Clinical Information Technology Clinician Adoption Innovation and Transformation Revolutionary HITy
33© 2009 DocsNetwork, Ltd.
Process Redesign Tasks
Current state value stream mapP d it b– Process and its sub-processes
– Collect baseline metrics
Future state value stream map– Detailed workflows– Role definition
l– Align committee structures– Policy/procedure definition
34© 2009 DocsNetwork, Ltd.
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
18© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Lean Value Stream Mapping
Simplify processes
Identify value steps
Reduce non-value added steps
Enable efficient care flow
Unit Secretary / RN Pharmacy
RN
Case Manager Social Worker
Supplier - Physician Customer - Patient
McKesson Star
DietaryRadiologyPhysical Therapy Laboratory
Lab order can be enteredin duplicates, or
confirmed in multiple orpartially filled.
Clarification needed
Call made to MD/RN/Dept. Supvr to clarify
orders
Unit Sectary confirm whatto order
Lab Order Clarification
Laboratory ResultSystem can notify byfax, pager or cell
RN review new order.Move step to 1st step
of adminstrationENVA
RN enters order intoMcKesson StarPhysician assesses Patient
Physician accesses andcollects additional pt.
information from Patient,Family, RN
Physician makes clinicaldecision
Physician gives verbal/phoneorder to RN
Physician places chart withorder in Order Rack
RN retrieves order fromOrder Rack
Faxes order to Pharmacy
Prints order inDepartment (For Rad,Lab, PT/OT, Dietary,
Respiratory, & Consultorders)
Unit Secretary calls Rad,Lab, Resp, SS, Dietary to
fast track orders
Unit Secretary writesorder into Kardex
Unit Secretary calls Respafter 2pm for EKG
Unit Secretary placeschart in Chart Rack RN reviews Order
RN ensures order isappropriate and confirms
order is transcribedappropriately in Kardex
Transcribesorder into the
MAR
RN directs and prioritizesthe order based on need
Transcribes order onRN's own work sheet
Administersfirst dose Rx
to pt.
Call Physician re:pt. status postSTAT orderadministered
InpatientSetting
Physician writes order onchart (Routine Orders)
VAVA
STAT orders can be verbal,phone and/or written
Documents inMAR when Rx is
given
VA
VA
VA
VA
Nurse writes verbal/phoneorder on Order Sheet
NVA
NVA
NVA
NVA
NVA
ENVA
NVA
For STAT Orders
NVANVA NVA NVA NVA
ENVA
Diagnostic Testing OrdersAppropriate Treatment =
Appropriate Diagnosis =
Broad Timing =
Appropriate Treatment =
Appropriate Diagnosis =
Broad Timing =
Treatment Orders
NVA
NVA
VA NVA
InitiateTreatment for
pt.
VA
VA
VA
Document caregiven
ENVA / VA
ENVA / VA
ENVA / VA
For STAT Orders
For Rx Order
RN interprets order andchecks for completeness.Call Physician to clarify, if
necessary.
Communicates withpt. on Plan of Care
PerformDiagnosticTest for pt.
Physicianacknowledgesorder fulfillment
Communicateswith CNA onPlan of Care
Off going and ongoing RNs
review and verifynew orders and
new MAR entries
At midnightthe new 24-hour MARprints out
RN reviewsnew and old
MAR
RN sendmemo topharmacy
withcorrections
RN correctsMAR
Old MAR isplaced in
Medical Recordand new MAR in
MAR book
NVA
NVA
RN Worksheet
MAR
VA
NVA
Route of administration =
Correct Drug =
Correct Dose =
Broad Timing =
Medication Orders
Nurse writes STATverbal/phone order
on Order Sheet
NVA
Physician assesses Patient
Physician collects pt.information from Patient,
Family& RN
Physician makes clinicaldecision
InpatientSetting
VAVA VA
Physician gives verbal/phonemedication order to RN
Physician writes medicationorder on chart (Routine
Orders include RegularlyScheduled and PRNmedication orders)
STAT orders can be verbal,phone and/or written
VA
VA
VA
Nurse writes verbal/phoneorder on Order Sheet
NVA
Please see MedicationAdministration in the Inpatient
Setting of CareCurrent State Value StreamMap (cVSM) for the differentiterations of the rest of this
process
Unit Sectary enters orderinto McKesson Star
NVA
RN retrieves order fromOrder Rack
NVA
Post testsresult to
medical recordand/or
McKesson Star
RN collect home medsinformation & verify with
Physician for continuation ornot
Laboratory call Panicvalues to MD or RN
Results faxed or enter inMcKesson STAR
STATS print directly toED
Routine printed to thefloor at midnight
MD accesses andenters data
through EPIC
Decision supportprovided by EPIC
MD enters orderdirectly into EPIC
Eliminate verbalorders; MD entersorder directly into
EPIC from home, officeand/or other location
RN enters phoneorder into EPIC.
Rarely
Barcode STATmeds directly intoMAR with order in
after the fact
RN adjust medadminstration
timing.
Order may go directlyinto departmental
system or print out
EPIC generatesKardex view
Review done in EPIC
Lab results feed intoEPIC
EPIC generates CNAworklist
Enter into EPIC
Acknwledge withinEPIC
Home Med inEPIC system if theMD uses EPIC in
office -RN toverify
Home Medsautomaticalypopulate first
order
Decision supportprovided by EPIC
MD enters orderdirectly into EPIC
Eliminate verbalorders; MD entersorder directly into
EPIC from home, officeand/or other location
Barcode on STATmeds recordsorder in EPIC
EPIC to generatethe MAR View
Electronic MAR
Collection of height, weightand allegies of pt.
Entered into EPICand avaliable for
clinicians
Clinical RPhround with MD -decision support
before orderwritten
Clinical RPhround with MD -decision support
before orderwritten
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Future State Admission Process Map
36© 2009 DocsNetwork, Ltd.
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
19© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Path Innovation of Clinical Processes
Required subject matter expertsProcess improvement– Process improvement
– Clinical content and evidence-based medicine– IT system design
Educating experts– Exchange knowledge
C t i i Cross training Teamwork
– Formation of long-standing working groups
© 2009 DocsNetwork, Ltd. 37
Clinical Transformation Needed
Utilize clinical technologiesI t li i l Impact clinical processes Enhance quality Achieve efficiencies Necessary focus
– Clinical strategy– Clinical business– Process redesign– Change management
38© 2009 DocsNetwork, Ltd.
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
20© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Summarizing Clinical Transformation
“every system is perfectly designed to every system is perfectly designed to achieve exactly the results it gets”
- Don Berwick, MDInstitute of Healthcare Improvement
39© 2009 DocsNetwork, Ltd.
Overview
Are We Receiving Value?L t’ M Fi t Let’s Measure First Clinical Information Technology Clinician Adoption Innovation and Transformation Revolutionary HITy
40© 2009 DocsNetwork, Ltd.
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
21© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Market Penetration of Robust Clinical Systems
Increasing investmentCost of doing business– Cost of doing business
Government and payor incentives Increasing use of IT
– EMR, PHR, EHR, CCR– Computerized provider order entry (CPOE)
Cli i l d i i (CDSS)– Clinical decision support system (CDSS)– Physician and patient portals
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New Job Descriptions
PhysiciansHigher level of work– Higher level of work
– Greater management responsibility
Nurses– Higher level of work– Delivery of physician level care
Oth h lth id Other healthcare providers– Delivery of nurse level care
© 2009 DocsNetwork, Ltd. 42
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
22© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Drivers of These New Roles
Health information technology– Electronic medical recordsElectronic medical records– Clinical decision support
• Alerts, reminders, guidelines, protocols, best practicesEvidence based medicineComparative effectiveness analysis
– Electronic information transfer• ePrescribing• Electronic case collaboration• Electronic case collaboration• RHIO/Health record banks
Reimbursement/business reforms– Address economic incentives
© 2009 DocsNetwork, Ltd. 43
African Proverb
Every morning in Africa, a gazelle wakes up.It knows it must run faster than the fastest It knows it must run faster than the fastest lion or it will be killed.Every morning a lion wakes up.It knows it must outrun the slowest gazelle or it will starve to death.It doesn’t matter whether you are a lion or a gazelle.
When the sun comes up, you better start running.
© 2009 DocsNetwork, Ltd. 44
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
23© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
References
Commonwealth Fund National Scorecard on U.S. Health System Performance, 2009.
Snapshot health care costs 101, 2009. California Healthcare F d ti 2009Foundation. 2009.
Nolte E, McKee CM. Measuring The Health of Nations: Updating an Earlier Analysis. Health Affairs. 2007;27(1):58-71.
Chaiken BP. Round Healthcare in a Flat World. Patient Safety and Quality Healthcare. 2006;3(3):12-13.
Friedman TL. The World is Flat. 2005. New York: Farrar, Straus and Giroux.
Chaiken BP. Path Innovation: Transcending Automation. Patient Safety and Quality Healthcare. 2005;2(3):46-47.
Chaiken BP. Revolutionary HIT: Cure for insanity. Patient Safety and Quality Healthcare 2007;4(6):10-11 Quality Healthcare. 2007;4(6):10 11.
Chaiken BP. Strategies for Success: Clinical HIT implementation. Patient Safety and Quality Healthcare. 2008:5(4):28-31.
Chaiken BP. Healthcare IT: Slogan or Solution? Patient Safety and Quality Healthcare. 2008;5(1):6.
www.logicalimages.com www.medting.com www.himss.org
© 2009 DocsNetwork, Ltd. 45
References
Chaiken BP. Useable clinical evidence-based guidelines…For real. Patient Safety and Quality Healthcare. 2005;2(1):14-16.
Chaiken BP Using IT to drive teamwork and patient safety Journal Chaiken BP. Using IT to drive teamwork and patient safety. Journal of Quality Health Care, 2003;2(1):19-20.
Chaiken BP, Holmquest DL. Patient safety: Modifying processes to eliminate medical errors. Journal of Quality Health Care. 2002;1(2):20-23.
Chaiken BP. Clinical decision support: Success through smart deployment. Journal of Quality Health Care, 2002:1(4):15-16.
Chaiken BP. Technology helps eliminate medical errors. Health Care Quality Means Business: Special Supplement to Managed Care. 2003;12(1):15-17.
Chaiken BP. Choosing clinical IT tools that matter to physicians. Health Management Technology. 2002;Sept.:20-22.
Chaiken BP. Physician adoption of technology linked to providing benefits. Journal of Quality Health Care, 2002;1(2):25-27.
46© 2009 DocsNetwork, Ltd.
Revolutionary Health IT: Path Innovation, Collaboration, and Transformation
24© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]
Barry P. Chaiken, MD, MPH, FHIMSSChief Medical OfficerDocsNetwork, Ltd.
47© 2009 DocsNetwork, Ltd.