Building Systems That Keep Patients Safer
Reflections on our state’s clinical informatics legacy, closing the gap at the bedside, and our strategic commitments for the year ahead.
I’m a pharmacist informaticist, which means I spend my days where clinical care meets technology. The question I come back to, again and again, is simple: how do we build systems that keep patients safer?
That question is older than most of us realize, and it has deep roots right here in Utah. In the 1960s, Dr. Homer Warner (the father of Medical Informatics) and his colleagues at LDS Hospital and the University of Utah built HELP, one of the first hospital information systems to put computerized decision support at the bedside. Utah was also home to one of the first academic departments of medical informatics in the country. When people talk about where clinical informatics began, they are talking about our backyard. Every one of us working in healthcare IT here inherits that legacy, and every one of us gets to add to it.
That legacy also comes with a warning. In 2007, researchers named a risk every informaticist should know: e-iatrogenesis, meaning patient harm caused at least in part by health information technology. Iatrogenesis is harm from care itself; the “e” means the harm came through the systems we build. A few years earlier, a landmark JAMA study had found 22 distinct ways a computerized order entry system could make medication errors more likely: confusing screens, dose defaults that didn’t match how clinicians thought, and allergy warnings that appeared only after the order was placed. The technology worked as designed. The design didn’t fit the work.
“Technology rarely fails loudly. It fails in the gap between how a system was built and how a nurse, pharmacist, physician, or patient actually uses it at 3 a.m.”
That’s the quiet truth of our field. Technology rarely fails loudly. It fails in the gap between how a system was built and how a nurse, pharmacist, physician, or patient actually uses it at 3 a.m. Alert fatigue, copy-forward notes, a drop-down list one row off: these are informatics problems, and they are patient safety problems. Closing those gaps takes clinicians, engineers, analysts, executives, and vendors in the same room, talking honestly. That’s what this chapter is for.
Healthcare IT in Utah is full of people doing hard, important work, often alone, often at 9 p.m., and often with no one to ask whether they’re seeing it right. Being part of Utah HIMSS means you don’t have to work that way. You can call someone who survived the go-live you’re about to start, or learn from a peer at another health system who already solved the interface problem you’re stuck on. You can find a mentor, become one, or both in the same conversation. I’ve watched careers, collaborations, and friendships begin at our events, and the generosity of this community continues to inspire me.
What we heard at our strategic retreat
This August, our board gathered in person for a strategic retreat. Around the table were a respiratory therapist turned informaticist, a chief data and privacy officer, a health system engineer, a revenue cycle leader, a graduate program director, and a former dentist now working in data security. We reaffirmed our vision: connecting Utah’s healthcare IT community around innovation, education, and impact. We also adopted a mantra for how we’ll work: we are a chapter that leads, not just meets. Every gathering should leave momentum behind it.
Then we asked a harder question: why do people really show up? One word came up in almost every answer: access. Access to experts. Access to the lived experience of peers who have already been through it. Access to honest, unbiased answers about what’s actually working in Utah. And, as one board member put it, access to the unwritten, because so much of what informaticists know isn’t in any textbook. It’s learned from each other.
From that conversation, we committed to a focused set of priorities, because too many priorities means no priorities:
Here’s what I believe: the best ideas in Utah healthcare don’t live inside one health system or one company. They live between us. Systems keep patients safe only when the people behind them keep learning from each other. Our job is to make it easy to find each other.
So look around. Take the survey. Join a committee. Come to the next event and introduce yourself to someone you don’t know. Bring the problem that’s keeping you up at night, because there’s a good chance someone here has already solved it or wants to solve it with you.
Utah helped invent this field. The year ahead is our chance to show what it can become. Come help make it great.
Get Involved With Utah HIMSS
Connect with over 350 regional leaders shaping healthcare technology across Utah. Discover educational sessions, join a committee, or register for upcoming chapter events.
