The transition from paper medical charts to electronic health records (EHRs) has streamlined many of the ways that health care is delivered in the Unites States and contributed to safety improvements in a number of areas.
Clinicians now have their patients’ information at their fingertips, along with new data tolls that help guide their decision and should reduce medical errors.
But the increased use of electronic health records has also given rise to new, unanticipated EHR safety challenges.
EHR Usability Survey Results – Reported Events
Of the seven usability categories, EHR challenges were reported in the following areas: Data Entry, Alerting, Interoperability, Visual Display, Availability of Information, System Automation & Defaults, and Workflow Support.
The chart below represents the frequency with which each usability category occurred following an EHR usability study:
Problems With EHR & Patient Safety
Health IT safety includes how EHRs have improved patient care and how their use may contribute to medical errors.
A number of reported safety events blame the EHR vendor for possibly contributing to patient harm. A study published in the March 2018 issue of JAMA examined these patient safety concerns.
Of 1.735 million reported safety events, 1956 of them explicitly mentioned an EHR vendor to blame and another 557 had language suggesting that the EHR usability contributed to possible patient harm.
Are the Numbers Accurate?
Lead researcher, Raj M. Ratwani, PhD, MA, believes the actual numbers are much higher.
He believes the main takeaway from his research is for the healthcare industry to recognize that some electronic record keeping systems suffer from lack of usability and this poor usability is associated with patient harm.
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Ratwani states that “electronic health usability is really the extent to which a clinician can safely, efficiently, effectively, and satisfactorily use an electronic health record or any technology for that matter.”
The reason he believes these numbers are much higher is that the study only looked at reports where the EHR vendor was mentioned specifically by name. But in their day-to-day work, clinicians rarely include the names of vendors or products when they write of safety reports. Additionally, only reports with explicit mentions of the top 5 vendors were included.
Furthermore, in general, medical and patient safety reports are known to be underreported, whether they involve an electronic health record or not.
Usability Issues of EHRs
- Definition: EHR data entry is difficult or not possible given the clinicians’ work process preventing the clinician from appropriately entering desired information
- Example: Pharmacist searched for the q24hr entry in the EHR by typing “q24hr”, which pulls up “Q24HP” and “Q24HR” but because she hit Enter a second time, the EHR populated all frequencies.
- Definition: EHR alerts or other feedback are inadequate because they are absent, incorrect or ambiguous
- Example: Allergy alert did not fire to prescriber even though gelatin allergy was listed elsewhere in EHR
- Definition: EHR interoperability is inadequate within components of the same EHR or from the EHR to other systems, hindering the communication of information
- Example: Patient was admitted as a trauma; the lab value did not flow into the EHR when the patient identification was confirmed
- Definition: EHR display of information is confusing, cluttered, or inaccurate resulting in clinician difficulty interpreting information
- Example: The orders in the EHR still showed the medication from the previous 2 administrations at the correct dose (unchanged), but dated for the previous day, which is subtle to notice in a long list of medications.
- Definition: EHR availability of clinically relevlant information is hindered because information is entered or stored in the wrong location or inaccessible
- Example: I placed postoperation orders in EHR; they were initiated and I signed them; the parianesthesia nurse called and said they had “failed”; on the orders menu all orders had failed; I was unable to place new orders, the nurse was unable to initiate old orders.
- Definition: The EHR automates or defaults to information that is unexpected, unpredictable, or not transparent to the clinician
- Example: Yesterday I was entering a patient’s warfarin dose to start Oct 1 at 8PM; when I entered in the time I did not realize the EHR had defaulted to October 2 at 8PM before pushing the order through.
- What is EHR Workflow Support,
- Definition: The EHR workflow is not supported due to a mismatch between the EHR and the mental state of the end user
- Example: A test ordered by the office through the EHR was “thyroid group”; the specimen was drawn and ordered by the laboratory; one part of the thyroid test was not performed because it was confusing translation between the physician order and the EHR
UsabilityThe International Organization for Standardization’s ISO 9241 standard defines usability as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use.”
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EHR Patient Safety Issues with Clinical ProcessesDefinitions and examples of Clinical Processes Issues identified in possible patient harm reports:
- Definition: Placing or relating to a clinical order (ex, admission, laboratory, referral, medication, procedure)
- Example: A physician put his orders in the EHR 15 minutes after the physician left the hospital; the orders should have appeared active but they were greyed out and appeared to be completed
- Definition: Relating to adverse drug reactions, wrong dose, duration, concentration, timing, route
- Example: Patient was given an additional dose of diltiazem today; tasked to start at 6 AM yet given at5:20 AMM by the night nurse; however another task fired at 10AM because it was written as daily; medication was given a second time by day nurse
- Definition: Accurate recording and reviewing of health information, status, treatment, planning of a patient.
- Example: Patient with 2 EHR encounters admitted; physician orders under 1 encounter, unit documentation on another encounter, cannot combine, cannot see orders on both encounters
- Definition: Receiving or viewing a clinical result on the intended patient
- Example: Gentamicin trough ordered for 5AM; it was sent to the lab and level came back as 1.6; a dose of gentamicin was given; nursing missed the level being high because it showed up as “within normal limits” in the EHR values; should have EHR recognize high levels for neonatal population
Summary of EHR problems
What we can garner from this report is that data integrity errors, erroneous workflows, and usability issues continue to plague EHR safety.
Problems can arise from health care professionals entering information incorrectly because the design of a system may not fit their workflow well or the layout may be confusing. In addition, records may not display information clearly – meaning clinicians may base decisions on incomplete data.
Executive leaders, both vendor and healthcare facilitators, must continue to embrace a culture of safety to mitigate any patient wellbeing concerns.
How Healthcare IT Developers Can Detect Safety Concerns
Health care facilities and health IT developers can detect safety concerns throughout a product’s development; as it is being designed, when it is submitted for government clarification, during implementation in hospitals and other institutions, and through staff training and use. EHR safety challenges can arise from the base design of a product, during install, implementation or customizations, or during unique workflows within a facility.
Doctors, nurses and other healthcare professionals are the front-line users of EHRs. Their daily use of these systems enables them to detect errors or potential problems. Their feedback and reporting to internal quality and safety leaders will contribute to fostering a culture throughout an organization.
Additionally, organizations like the American Medical Association is developing standards for EHR and will use this framework to work with physicians, vendors, policymakers, health care systems and researchers to drive EHR improvements that can advance the delivery of high-quality care.
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