Healthcare // Electronic Health Records
Commentary
10/26/2011
09:12 AM
Paul Cerrato
Paul Cerrato
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EHR Worst Practices

Just a partial list of EHR snafus emphasizes the need for a better system of tracking errors.

We need the equivalent of the National Transportation Safety Board to monitor EHRs, according to Dean Sittig, PhD, a member of the faculty at the School of Biomedical Informatics, the University of Texas Health Science Center at Houston (UTHealth). After listening to his presentation at this week's American Medical Informatics Association (AMIA) Scientific Sessions, I can see the wisdom of that suggestion.

NTSB was launched in 1926, when the automotive industry was in its infancy and few people thought about all the fatalities that lie ahead. Over the years, it has been responsible for insisting on speed limits, seatbelts, airbags, and a host of other invaluable safety measures.

An NTSB-like organization for EHRs would at the very least provide a reporting mechanism to keep track of incidents and life-threatening consequences of misusing e-records. More importantly, it could police vendors and healthcare providers who repeatedly ignore these dangers.

During his presentation, Sittig was quick to point at that errors can occur at any stage in the life cycle of an EHR, during design and development, implementation, or post-installment evaluation. He went on to describe several areas in which one can expect to see problems, which are not limited to computer glitches. Many problems are due to the way humans interact with machines. But unless we have a NTSB-like system to track all the errors and categorize them, EHR designers and end users will have a much harder time systematically fixing them.

[ For more background on e-prescribing tools, see 6 E-Prescribing Vendors To Watch. ]

And statistics suggest we are doing a poor job of tracking these snafus without some sort of government or industry oversight. Over the last 18 years, for instance, the FDA has received reports of only 120 EHR-specific errors. There is no way that number can be accurate; it only tells us that such errors are grossly underreported.

One problem that needs to be tracked is missing or inaccurate clinical content within an EHR. Probably the most notorious mistake that Sittig mentioned occurred because of a mapping error in England's National Health Service. It resulted in patients who were supposed to get a prescription for Zyban, a medication to help them stop smoking, being prescribed Viagra instead.

Other reports suggest that even when an EHR churns out correct information, it's not always reaching the clinicians who need to know, or they are simply not acting on the information. In one study, of the 1,163 lab results that were sent out as electronic alerts, about one of every 10 were ignored by physicians. Worse yet, in a separate investigation, 7-8% of abnormal imaging results were never followed up by physicians.

Another pain point for IT managers and clinicians: EHR-generated alerts sometimes have unintended consequences. An experiment done at the University of Pennsylvania showed that a hard-stop alert can reduce the likelihood of ordering dangerous meds. But the investigators also found that in some cases, these roadblocks actually resulted in dangerous delays in ordering meds for some patients who really needed them.

These are only a few of the snafus one can expect to see when computers and people interact, which is all the more reason for IT departments to thoroughly measure and monitor the performance of their e-record systems. Our EHRs need seatbelts, speed limits, airbags, and a variety of still unimagined features if we ever hope to safely navigate this new highway.

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MedInformaticsMD
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MedInformaticsMD,
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11/7/2011 | 2:27:49 PM
re: EHR Worst Practices
FDA's CDRH Director Shuren stated that FDA's knowledge of these events likely represents the "tip of the iceberg" for reasons in the FDA memo available here: http://hcrenewal.blogspot.com/...

And, here are recent cases of EHR-related snafus:

http://hcrenewal.blogspot.com/...

http://www.ischool.drexel.edu/...

pcerrato109
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pcerrato109,
User Rank: Apprentice
10/27/2011 | 1:13:25 PM
re: EHR Worst Practices
Thanks for your feedback, Chris. I'm sure there are a lot of other QA folks out there who would likewise benefit from such a national database of incidents. As you say: Why reinvent the wheel.

Paul Cerrato
Editor, InformationWeek Healthcare
Chris Spera
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Chris Spera,
User Rank: Apprentice
10/26/2011 | 8:11:54 PM
re: EHR Worst Practices
I agree, Paul. I am a software QA guru by day and have nearly 20 years experience in a heathcare setting. I've been a regualtory affairs executive and have been responsible for EMR/EHR Integration QA at a local Chicago hospital. I was also one of the hospital's IT incident managers and was responsible for analyzing IT incident data for trends and for tracking the implementation of corrective and preventive actions.

It would have been WONDERFUL to have access to a nationally based incident database to be able to track and research monitored incidents and their corrective/preventive actions, as it would have made my job a lot easier. I hate reinventing the wheel if I don't have to, and access to something like that could have saved a lot of time and energy, especially during implementations when I also had to manage the command center and report on implementation bug status to the hospital's executive management.
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