ABSTRACT
EI&K strategies to improve communication, between computer systems and humans, and to make use of the best resources possible could help prevent errors and patient harm. This chapter identifies common occurrences of EI&K transfer gaps. It provides a sharp-end example, adapted from a case report for the Agency for Healthcare Research and Quality (AHRQ), illustrates serious unintended consequences caused by health information technology (HIT), demonstrating that the speed and convenience of electronic systems linked to the transfer clinical information does not guarantee their accuracy. The HIT issues affecting the safety and effectiveness of information sharing and contributing to gaps includes: Poor hospital work processes, Data fragmentation, Lack of standardization, Proprietary interests, Under-reporting of HIT problems, and difficult interfaces combined with user training issues. By thinking through the process of how rounds take place in an academic medical center, several critical junctures in evidence and information transfer are revealed.
