Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system

Abstract

Context: "Meaningful use" of electronic health records to improve quality of care has remained understudied. We evaluated an approach to improving patients' safety and quality of care involving the secondary use of data from a hospital electronic prescribing and decision support system (ePDSS).

Methods: We conducted a case study of a large English acute care hospital with a well-established ePDSS. Our study was based on ethnographic observations of clinical settings (162 hours) and meetings (28 hours), informal conversations with clinical staff, semistructured interviews with ten senior executives, and the collection of relevant documents. Our data analysis was based on the constant comparative method.

Findings: This hospital's approach to quality and safety could be characterized as "technovigilance." It involved treating the ePDSS as a warehouse of data on clinical activity and performance. The hospital converted the secondary data into intelligence about the performance of individuals, teams, and clinical services and used this as the basis of action for improvement. Through a combination of rapid audit, feedback to clinical teams, detailed and critical review of apparent omissions in executive-led meetings, a focus on personal professional responsibility for patients' safety and quality care, and the correction of organizational or systems defects, technovigilance was-based on the hospital's own evidence-highly effective in improving specific indicators. Measures such as the rate of omitted doses of medication showed marked improvement. As do most interventions, however, technovigilance also had unintended consequences. These included the risk of focusing attention on aspects of patient safety made visible by the system at the expense of other, less measurable but nonetheless important, concerns.

Conclusions: The secondary use of electronic data can be effective for improving specific indicators of care if accompanied by a range of interventions to ensure proper interpretation and appropriate action. But care is needed to avoid unintended consequences.

Keywords: electronic health records; ethnography; meaningful use; medication errors; patient safety; quality of care.

FIGURE 1

Antibiotic dose omission rates at Rayburn Hospital, plotted at four-week intervals. Source: Data from ePDSS at Rayburn Hospital.