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Date: Nov. 20, 2003
Contacts: Christine Stencel, Media Relations Officer
Chris Dobbins, Media Relations Assistant
Office of News and Public Information
202-334-2138; e-mail <>


Reducing Medical Errors Requires National Computerized Information Systems;
Data Standards Are Crucial to Improving Patient Safety

WASHINGTON -- To significantly reduce the tens of thousands of deaths and injuries caused by medical errors every year, health care organizations must adopt information technology systems that are capable of collecting and sharing essential health information on patients and their care, says a new report by the Institute of Medicine of the National Academies. These systems should operate seamlessly as part of a national network of health information that is accessible by all health care organizations and that includes electronic records of patients' care, secure platforms for the exchange of information among providers and patients, and data standards that will make health information uniform and understandable to all, said the committee that wrote the report.

"When it comes to safety, the health care industry needs to borrow a page from the airline industry," said committee chair Paul Tang, chief medical information officer, Palo Alto Medical Foundation, Palo Alto, Calif. "Pilots have instantaneous access to the data they need on weather conditions and mechanical functions to make informed decisions about navigation, delays, and midcourse corrections. When accidents or near misses occur, the industry can analyze these events, and the resulting information can be used to prevent future errors. In health care, no such universal information system exists."

While some hospitals, medical groups, and other health care organizations have installed computer systems to manage patient information, a national infrastructure for standardized data collection and exchange is needed because patients often receive services from many different providers. Routine use of electronic health records would give health care providers and patients immediate access to complete patient information as well as tools to guide decision-making and help prevent errors. "It is time to shift the emphasis of patient safety programs from a strategy of reporting, focused on injuries after they have occurred, to one of prevention aimed at providing safe and effective care in the first place," Tang said.

However, without standards for how and what data is collected, the different systems used in various organizations may not be compatible. "The lack of data standards is a key obstacle to the adoption of both electronic health records and data exchange systems," said committee vice chair Molly Joel Coye, CEO, Health Technology Center, San Francisco. "Physicians and other providers have hesitated to invest in data systems, reasonably so, knowing that their own medical record system might not be able to exchange important patient information with local pharmacies, hospitals, or even other physicians."

To facilitate the routine use of electronic health records, the health care sector must develop and use standardized formats for these records, which allow providers to record information about patients' health at the point of care. In addition, uniform formats and data standards for reporting information on near misses -- mishaps that were caught before harm occurred -- as well as events caused by mistakes must be developed and adopted so that the industry can learn how to prevent future errors.

A 1999 IOM report estimated that up to 98,000 deaths occur every year in U.S. hospitals as a result of medical errors. Recent studies show that tens of thousands of additional errors occur in nursing homes and clinics. Moreover, patients in all health care settings receive on average just slightly over half the tests, procedures, and other care that is recommended for their conditions, according to another study.

The private sector can be expected to invest a significant portion of the capital required to build a national system of computerized health information and data sharing. However, federal investments should support the development of critical building blocks of this infrastructure, especially those that are unlikely to receive adequate support from the private sector, such as a secure platform for data exchange. The government also should provide financial incentives to spur private-sector development of electronic health record systems. The committee acknowledged that sizable investments will be needed to build the infrastructure, but noted that the resulting tools and information could yield significant benefits for other areas as well, including homeland security and public health.

Uniform information technology standards for the collection, storage, and dissemination of health information are crucial to the national infrastructure. The U.S. Department of Health and Human Services should take the lead in establishing a public-private partnership to develop and promote national health data standards. The report outlines a plan to accelerate the development of data standards in three key areas: clinical terminologies, exchange of data among computers, and representation of medical information in computer programs.

Government health care programs -- which pay for more than 40 percent of all health care expenditures – should encourage adoption of these national data standards by incorporating them into their contractual and regulatory requirements. For example, adherence to the standards should be one of the conditions for participation in Medicare programs.

As part of the effort to achieve an acceptable standard of patient safety, all health care settings must establish comprehensive patient safety programs operated by trained personnel, the report adds. They must establish a culture in which patient safety is a top priority.

The study was sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.

Patient Safety: Achieving a New Standard for Care is available on the Internet at Copies of the report will be available for purchase early next year from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information (contacts listed above).

Board on Health Care Services

Committee on Data Standards for Patient Safety

Paul C. Tang, M.D. (chair)
Chief Medical Information Officer
Palo Alto Medical Foundation
Palo Alto, Calif.

Molly J. Coye, M.D., M.P.H. (vice chair)
Chief Executive Officer
Health Technology Center, and
Senior Fellow
Institute for the Future
San Francisco

Suzanne Bakken, R.N., D.N.Sc., F.A.A.N.
Alumni Professor of Nursing, and
Professor of Biomedical Informatics
Columbia University
New York City

E. Andrew Balas, M.D., Ph.D.
School of Public Health, and
Professor of Health Policy
Saint Louis University
St. Louis

David W. Bates, M.D., M.Sc.
Division of General Medicine
Brigham and Women's Hospital;
Medical Director
Clinical and Quality Analysis
Partners Healthcare System; and
Associate Professor of Medicine
School of Medicine
Harvard University

John R. Clarke, M.D., F.A.C.S.
Professor of Surgery
Drexel University;
Adjunct Professor of Computer and Information Science
University of Pennsylvania; and
Adjunct Senior Fellow
Leonard Davis Institute of Health Economics

David C. Classen, M.D., M.S.
Vice President
First Consulting Group, and
Associate Professor of Medicine and Consultant in Infectious Diseases
School of Medicine
University of Utah
Salt Lake City

Simon P. Cohn, M.D., M.P.H., F.A.C.E.P.
National Director
Health Information Policy
Kaiser Permanente Medical Care Program
Oakland, Calif.

Carol Cronin, M.S.W., M.S.
Independent Consultant
Annapolis, Md.

Jonathan S. Einbinder, M.D., M.P.H.
Assistant Professor
Harvard Medical School, and
Corporate Manager
Partners Healthcare Information Systems

Larry D. Grandia, M.E.
Chief Technology Officer and
Executive Vice President
Premier Inc.
San Diego

W. Ed Hammond, Ph.D.
Professor Emeritus
Division of Medical Informatics
Duke University
Durham, N.C.
Brent C. James, M.D., M.Stat.
Executive Director
Institute for Health Care Delivery Research, and
Vice President
Medical Research and Continuing Medical Education
Intermountain Health Care
Salt Lake City

Kevin B. Johnson, M.D., M.S.
Associate Professor and Vice Chair
Biomedical Informatics, and
Associate Professor
Department of Pediatrics
School of Medicine
Vanderbilt University
Nashville, Tenn.

Jill Rosenthal, M.P.H.
Project Manager
National Academy for State Health Policy
Portland, Maine

Tjerk W. van der Schaaf, Ph.D.
Associate Professor
Human Factors in Risk Control
Eindhoven University of Technology
Eindhoven Safety Management Group
Department of Technology Management
Eindhoven, Netherlands


Philip Aspden, Ph.D., M.A.
Study Director