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Safety Recommendation Details

Safety Recommendation H-18-021
Details
Synopsis: In November 2016, the NTSB began the investigation of two crashes involving school buses. Each crash was initiated when the driver lost control of the bus. In the November 1 crash in Baltimore, Maryland, the driver was epileptic and suffered a seizure. In the November 21 crash in Chattanooga, Tennessee, the driver was speeding while using a cell phone and ran off the road. In both cases, the school bus operators were private for-hire motor carriers. Although the specific safety issues differed, the crashes shared one common factor: poor driver oversight by both the school districts and the contracted motor carriers, which resulted in unsafe operation of the school buses. Between the two crashes, 12 people died and 37 were injured. The crash investigations focused on the following safety issues: school districts’ lack of oversight of student transportation providers; poor management of unsafe school bus drivers by the motor carriers and school districts; medically unfit school bus drivers; commercial driver license fraud; occupant protection in large school buses; and the benefits of electronic stability control, automatic emergency braking, and event data recorders. The NTSB made safety recommendations to the Federal Motor Carrier Safety Administration; the National Highway Traffic Safety Administration (NHTSA); the states of Florida, Louisiana, New Jersey, and New York; 42 states, the District of Columbia, and the territory of Puerto Rico—which lack requirements for lap/shoulder belts on large school buses; the state of Maryland; the Maryland Department of Education; the Maryland Motor Vehicle Administration; five school bus transportation associations; National Express LLC; seven school bus manufacturers; five electronic health record companies; and Concentra, Inc. The report also reiterates four recommendations to NHTSA and reclassifies a recommendation to the Baltimore City Public Schools.
Recommendation: TO EPIC, CERNER CORPORATION, ECLINICALWORKS, MEDITECH, AND NEXTGEN HEALTHCARE: Develop decision support for the evaluation of nontraumatic loss of consciousness episodes or for a diagnosis of epilepsy that will notify providers of the patient’s occupation, such as commercial driver; and remind them to address the occupational and driving status of the patient, including the opportunity to inform the state licensing agency of concerns about the patient’s driving.
Original recommendation transmittal letter: PDF
Overall Status: Open - Await Response
Mode: Highway
Location: Chattanooga, TN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: HWY17MH009
Accident Reports: Preliminary Report: HIGHWAY - HWY17MH009
Report #: SIR-18-02
Accident Date: 11/21/2016
Issue Date: 6/21/2018
Date Closed:
Addressee(s) and Addressee Status: Cerner Corporation (Open - Await Response)
eClinicalWorks (Open - Acceptable Response)
Epic Systems Corporation (Closed - Acceptable Action)
Medical Information Technology, Incorporated (dba MEDITECH) (Open - Await Response)
NextGen Healthcare (Open - Await Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Epic Systems Corporation
Date: 11/2/2018
Response: We are pleased that you updated your software with the recommended decision support tools. We commend your prompt action to improve medical provider decision-making and your development of materials to help inform your customers of these changes. These actions satisfy Safety Recommendation H-18-21, which is classified CLOSED--ACCEPTABLE ACTION.

From: Epic Systems Corporation
To: NTSB
Date: 9/15/2018
Response: -From Adam Whitlach, Epic Research and Development: Thank you for your correspondence regarding NTSB/SIR-18/02. We appreciate the opportunity to review and respond to safety recommendation H-18-21. In response to the recommendation, we recently updated our software to increase the visibility of a patient’s occupation. This display has been implemented in the Epic Foundation System, which serves as the starting environment for new organizations implementing Epic’s software, and also the collection of best practices and recommendations for organizations already using the software. In addition, in the August 2018 edition of the Foundation System, we have created new decision support tools in the form of best practice advisories (BPAs), which are the standard mechanism to draw clinical attention to important information or to the need for further action. These BPAs 1) alert a clinician to the fact that the patient has a potentially high risk occupation, such as driver, pilot, or machine operator and 2) alert a clinician in a more urgent way if a diagnosis is entered into the record that indicates a seizure disorder or a tendency to lose consciousness in the context of a high-risk occupation. In the latter case, the clinician is reminded that reporting to state or federal agencies may be required. Finally, we have created corresponding documentation for our customers, which will accompany a customer-wide announcement on Epic’s customer forum regarding this new build. Provider organizations already using Epic will be advised to configure the software based on our recommendation.

From: NTSB
To: Epic Systems Corporation
Date: 6/21/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On May 22, 2018, the NTSB adopted its report Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee, NTSB/SIR-18/02. The details of these investigations and the resulting safety recommendations may be found in the attached report, which can also be accessed at www.ntsb.gov. Among the safety issues identified in the Baltimore school bus crash was a school bus driver with poorly controlled epilepsy, who had many health-care visits to offices, clinics, emergency departments, and hospitals. None of the records for these visits documented that a health-care provider had addressed the patient’s driving status or risks associated with his occupation. Since 1991, none of the health-care providers who knew of his epilepsy had reported him to the state driver licensing agency. There were many other opportunities for the school bus driver’s medical condition to come to the attention of enforcement authorities, and the NTSB has made a number of safety recommendations to address these loopholes. Among them is one new recommendation issued to Epic, which can be found on page 78 of the report. Our expectation is that Epic will develop decision support inside its information systems to ensure that clinical providers are aware of the occupation of patients with lapses of consciousness (such as seizures) and are reminded to address driving status. Finally, the goal is to remind clinical providers of the opportunity to report medically unfit drivers to the state driver licensing board. There is reasonable evidence from Canada that having health-care providers discuss driving status with such patients significantly decreases their crash risk and thereby increases their safety and the safety of the traveling public. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement it. When replying, please refer to the safety recommendation by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 10 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.

From: NTSB
To: Cerner Corporation
Date: 6/21/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On May 22, 2018, the NTSB adopted its report Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee, NTSB/SIR-18/02. The details of these investigations and the resulting safety recommendations may be found in the attached report, which can also be accessed at www.ntsb.gov. Among the safety issues identified in the Baltimore school bus crash was a school bus driver with poorly controlled epilepsy, who had many health-care visits to offices, clinics, emergency departments, and hospitals. None of the records for these visits documented that a health-care provider had addressed the patient’s driving status or risks associated with his occupation. Since 1991, none of the health-care providers who knew of his epilepsy had reported him to the state driver licensing agency. There were many other opportunities for the school bus driver’s medical condition to come to the attention of enforcement authorities, and the NTSB has made a number of safety recommendations to address these loopholes. Among them is one new recommendation issued to Cerner Corporation, which can be found on page 78 of the report. Our expectation is that Cerner will develop decision support inside its information systems to ensure that clinical providers are aware of the occupation of patients with lapses of consciousness (such as seizures) and are reminded to address driving status. Finally, the goal is to remind clinical providers of the opportunity to report medically unfit drivers to the state driver licensing board. There is reasonable evidence from Canada that having health-care providers discuss driving status with such patients significantly decreases their crash risk and thereby increases their safety and the safety of the traveling public. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement it. When replying, please refer to the safety recommendation by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 10 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.

From: NTSB
To: eClinicalWorks
Date: 11/2/2018
Response: We note that you are working to update your software with the recommended decision support tools, and we are encouraged by your plans to develop best practices guidance about your system to inform your customers of currently available benefits. Until your system updates are complete, Safety Recommendation H-18-21 is classified OPEN--ACCEPTABLE RESPONSE. Thank you for your recommendation about interoperability standards and your offer to share information about commercial driver medical conditions. We do not have the authority to accept such information; we are only able to obtain information when drivers are involved in crashes we are investigating. We appreciate your suggestions to improve commercial driver safety. Please update us at correspondence@ntsb.gov on your progress toward implementing this recommendation, and do not submit both an electronic and a hard copy of the same response.

From: eClinicalWorks
To: NTSB
Date: 9/19/2018
Response: -From Whitney Horrell, Senior Legal Counsel: Thank you for contacting us regarding the safety issues contained in “Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee, NTSB/SIR 18/02”. Here at eClinicalWorks, LLC we take patient safety very seriously and strive to make enhancements to our electronic health record (“EHR”) system for our customers. We appreciate the opportunity to respond to this report and hope to enhance our system to address your concerns. Below, we have set out the safety recommendations you asked us to comment on along with our plan to address these concerns. I. 4.4.2 Safety Recommendations "NTSB recommends that Epic, Cerner Corporation, eClinicalWorks, MEDITECH and NextGen Healthcare develop decision support for the evaluation of nontraumatic LOC episodes or for a diagnosis of epilepsy that will notify providers of the patient’s occupation, such as commercial driver; and remind them to address the occupational and driving status of the patient, including the opportunity to inform the state licensing agency of concerns about the patient’s driving. (H- 18-21)". II. Problem Definition Commercial truck drivers are required to have a medical examination in order to obtain and retain a Commercial Driving License (“CDL”). See 49 CFR §383.71(h). Drivers who experience loss of consciousness episodes or are diagnosed with epilepsy or another seizure disorder require additional monitoring by a physician to address the occupational and driving status of the patient. Additionally, physicians are required to inform the state driver licensing agency of any concerns about the patient's driving, including if the driver is unfit to drive. III. eClinicalWorks' Plan Short Term •?Currently, within Version 11 of the eClinicalWorks EHR, customers have the ability to create a rule via the eClinicalWorks Clinical Rule Engine module. In a rule, customers are able to create structured data and run rules based upon the value of the data. For example, a structured data point of "CDL" and a Boolean answer of "Yes" will trigger the rule to run, alerting the physician of the occupation of Commercial Driver who holds a CDL. •?eClinicalWorks will create a “Best Practices” guide with a supporting video to educate physicians and their medical staff about best practices within the EHR for the use of structured data and clinical rule engines. The completion and distribution of this guide and supplementary instructional video to its customers is anticipated to occur First Quarter 2019. Long Term •?eClinicalWorks will develop a Clinical Decision Support System (“CDSS”) alert specifically for providers to assist in the decision support of patients with a diagnosis of loss of consciousness episode, epilepsy or any other seizure disorder who also have an occupation as a commercial driver holding a CDL. The alert will not be able to be suppressed, and the intent is to always alert the physician of the diagnosis when a patient is listed as being employed as a commercial driver. A new CDSS Alert available for customers is anticipated to be available in 2019. •?eClinicalWorks could develop a software application programming interface (“API”) for use by the NTSB. This API would connect our EHR to the NTSB to provide information on patients who are commercial drivers as well as their relevant medical conditions, such as (i) a diagnosis of epilepsy or any other seizure disorder, or (ii) patient prescriptions for an anticonvulsant such as Tegretol or the generic equivalent of carbamazepine. This API would be dependent upon receiving all appropriate HIPAA consents from patients to permit the sharing of their protected health information. If this is something the NTSB would like to pursue, please reach out to us and we can discuss this option further. IV. Additional Recommendations from eClinicalWorks eClinicalWorks encourages NTSB to advise physicians to utilize the interoperability standards present in EHR systems to gain useful information about the patient, such as the patient’s “Problem List” or “Medication List” previously documented by other physicians. This could assist in circumstances where the physician completing the patient’s examination required for the patient’s Commercial Driver Medical Certification is not the patient’s primary care physician. Thank you for including us in this discussion. We appreciate the opportunity to make improvements to our EHR which could have a life-saving impact on the community.

From: NTSB
To: eClinicalWorks
Date: 6/21/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On May 22, 2018, the NTSB adopted its report Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee, NTSB/SIR-18/02. The details of these investigations and the resulting safety recommendations may be found in the attached report, which can also be accessed at www.ntsb.gov. Among the safety issues identified in the Baltimore school bus crash was a school bus driver with poorly controlled epilepsy, who had many health-care visits to offices, clinics, emergency departments, and hospitals. None of the records for these visits documented that a health-care provider had addressed the patient’s driving status or risks associated with his occupation. Since 1991, none of the health-care providers who knew of his epilepsy had reported him to the state driver licensing agency. There were many other opportunities for the school bus driver’s medical condition to come to the attention of enforcement authorities, and the NTSB has made a number of safety recommendations to address these loopholes. Among them is one new recommendation issued to eClinicalWorks, which can be found on page 78 of the report. Our expectation is that eClinicalWorks will develop decision support inside its information systems to ensure that clinical providers are aware of the occupation of patients with lapses of consciousness (such as seizures) and are reminded to address driving status. Finally, the goal is to remind clinical providers of the opportunity to report medically unfit drivers to the state driver licensing board. There is reasonable evidence from Canada that having health-care providers discuss driving status with such patients significantly decreases their crash risk and thereby increases their safety and the safety of the traveling public. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement it. When replying, please refer to the safety recommendation by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 10 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.

From: NTSB
To: Medical Information Technology, Incorporated (dba MEDITECH)
Date: 6/21/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On May 22, 2018, the NTSB adopted its report Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee, NTSB/SIR-18/02. The details of these investigations and the resulting safety recommendations may be found in the attached report, which can also be accessed at www.ntsb.gov. Among the safety issues identified in the Baltimore school bus crash was a school bus driver with poorly controlled epilepsy, who had many health-care visits to offices, clinics, emergency departments, and hospitals. None of the records for these visits documented that a health-care provider had addressed the patient’s driving status or risks associated with his occupation. Since 1991, none of the health-care providers who knew of his epilepsy had reported him to the state driver licensing agency. There were many other opportunities for the school bus driver’s medical condition to come to the attention of enforcement authorities, and the NTSB has made a number of safety recommendations to address these loopholes. Among them is one new recommendation issued to MEDITECH, which can be found on page 78 of the report. Our expectation is that MEDITECH will develop decision support inside its information systems to ensure that clinical providers are aware of the occupation of patients with lapses of consciousness (such as seizures) and are reminded to address driving status. Finally, the goal is to remind clinical providers of the opportunity to report medically unfit drivers to the state driver licensing board. There is reasonable evidence from Canada that having health-care providers discuss driving status with such patients significantly decreases their crash risk and thereby increases their safety and the safety of the traveling public. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement it. When replying, please refer to the safety recommendation by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 10 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.

From: NTSB
To: NextGen Healthcare
Date: 6/21/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On May 22, 2018, the NTSB adopted its report Selective Issues in School Bus Transportation Safety: Crashes in Baltimore, Maryland, and Chattanooga, Tennessee, NTSB/SIR-18/02. The details of these investigations and the resulting safety recommendations may be found in the attached report, which can also be accessed at www.ntsb.gov. Among the safety issues identified in the Baltimore school bus crash was a school bus driver with poorly controlled epilepsy, who had many health-care visits to offices, clinics, emergency departments, and hospitals. None of the records for these visits documented that a health-care provider had addressed the patient’s driving status or risks associated with his occupation. Since 1991, none of the health-care providers who knew of his epilepsy had reported him to the state driver licensing agency. There were many other opportunities for the school bus driver’s medical condition to come to the attention of enforcement authorities, and the NTSB has made a number of safety recommendations to address these loopholes. Among them is one new recommendation issued to NextGen Healthcare, which can be found on page 78 of the report. Our expectation is that NextGen will develop decision support inside its information systems to ensure that clinical providers are aware of the occupation of patients with lapses of consciousness (such as seizures) and are reminded to address driving status. Finally, the goal is to remind clinical providers of the opportunity to report medically unfit drivers to the state driver licensing board. There is reasonable evidence from Canada that having health-care providers discuss driving status with such patients significantly decreases their crash risk and thereby increases their safety and the safety of the traveling public. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement it. When replying, please refer to the safety recommendation by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.