Healthcare // Electronic Health Records
News
3/26/2013
11:17 AM
Connect Directly
RSS
E-Mail
50%
50%

Healthcare Workarounds Expose EHR Flaws

Doctors and staff often fall back on paper documents to compensate for poorly designed electronic health record systems, says study.

9 Mobile EHRs Compete For Doctors' Attention
9 Mobile EHRs Compete For Doctors' Attention
(click image for larger view and for slideshow)
Physicians and medical practice staff members are using both paper-based and computer-based workarounds to overcome real and perceived deficiencies in their electronic health records (EHRs), according to a new study in the Journal of the American Medical Informatics Association (JAMIA). These workarounds, which are consistent across institutions, "suggest common challenges in outpatient clinical settings and failures to accommodate these challenges in EHR design," the study said.

The researchers directly observed clinical workflows at 11 primary care clinics in different healthcare organizations: two VA medical centers, Partners Healthcare in Boston and the Regenstrief Institute in Indianapolis. In total, 120 clinic staff and providers were observed caring for 118 patients.

The study, "Paper- and computer-based workarounds to electronic health record use at three benchmark institutions," classified workarounds in several different categories, including one that the researchers termed "no correct path." In this category, computer-based workarounds were created because a desired option did not exist in the EHR workflow. For example, doctors might tell patients to split blood pressure pills, but there was no way to record that in the EHR, leading to incorrect timings for prescription renewals. The study also cited EHR reminders that kept popping up after a colonoscopy had been scheduled but not completed. A nurse clicked on the box saying the test had been declined to turn off the alert.

[ Are you making the mistake of shopping for an EHR without first considering your office workflow? Learn why Technology Alone Isn't Healthcare's Savior. ]

Several workarounds were related to efficiency: For example, when the staff member who entered vital signs and responses to health screening questions into the EHR was absent, the information would either be written down on paper for later data entry or patients would be asked to fill out paper questionnaires.

Cutting and pasting progress notes, vital signs or health maintenance information from earlier notes -- frequently done to improve efficiency -- was classified as a workaround because it was against hospital policy. This type of "cloning" has ignited a political controversy over the potential use of EHRs to defraud Medicare.

"Awareness" workarounds served as a means of communication between co-workers. In some cases, staff members would write down vitals data or results from a health screening form on a paper encounter form so that physicians would have that information available to them during a physical examination.

"Memory" workarounds included notes for completing future tasks or following up patient problems. One nurse wrote "flu shot" on a scrap of paper to remind herself to administer the shot. A physician assistant kept printouts from the EHR to remind himself to finish unsigned progress notes.

Some workarounds were designed to overcome glaring design errors in EHRs. For example, a physician using one EHR could not place an order without closing the progress note he was working on because if he did so, the note would be deleted. To get around this problem, he had to log on again to enter the orders.

Some providers kept separate paper-based notes because they didn't trust that the EHR would be available when they needed it to document visits. Even if it were available, some tasks were judged to be too complex for the EHR. "Some workarounds suggest that complicated tasks are difficult to program within the EHR or programmers do not know what work processes need cognitive support from the EHR," the researchers said.

Mark Anderson, a health IT consultant in Montgomery, Texas, told InformationWeek Healthcare that the study's findings matched his own observations. "Eighty-five percent of the practices I work with are not using the EHR the way it was designed," he said. "They create workarounds."

In most cases, he said, this can be attributed to design flaws in the EHR rather than to doctors' resistance to the technology. "It's because the EHR slows them down so much that they can't use all the functionality. Also, many doctors buy systems that aren't built for their specialties. They buy a primary-care-based product that isn't designed for cardiologists or GI doctors."

Many EHRs lack big chunks of functionality that physicians need to accomplish their daily work, he said. For example, if an EHR had an internal messaging system, staff members wouldn't have to write reminders to each other on pieces of paper. But the majority of EHRs don't include internal messaging, Anderson said. The leading EHRs do, but the suppliers of many other products say, "It's not required for Meaningful Use, so we don't need it," he noted.

Anderson estimated that the EHR functionality required to show Meaningful Use stage 1 represents less than 10% of what a physician needs to perform his or her daily work, relying only on the EHR for documentation, reminders, messaging, orders and other necessary functions.

Comment  | 
Print  | 
More Insights
Comments
Oldest First  |  Newest First  |  Threaded View
SeanDo40
50%
50%
SeanDo40,
User Rank: Apprentice
3/26/2013 | 6:40:04 PM
re: Healthcare Workarounds Expose EHR Flaws
I experienced this just the other night. I was at my son's karate class and sitting in the parent's area was a nurse, still in scrubs, with a spiral bound notebook in her hand. The title on the notebook "patient notes". On her knees balanced a Toshiba Tecra laptop. She was busy transcribing the paper notes to an EHR application.
Couple of things come to mind. A) With context aware security she should never be allowed access to the EHR app when outside the geo fence of the hospital. B) How does this practice not violate several compliancy rules? C) Why does she find it easier to do double work than use the technology at the hospital in real time?
pbug
50%
50%
pbug,
User Rank: Strategist
3/28/2013 | 1:43:59 AM
re: Healthcare Workarounds Expose EHR Flaws
In one ED near me, the new EHR was down again recently; staff were back to doing everything on paper. In that ED, this means that everything takes much, much longer to do. At a hospital one county over, one doctor tells me that she takes paper notes all day long, and then stays after shift to type everything in, because if not, the system is so bad that she can't actually properly examine and treat her patients in the allotted time. BTW, her hand writing is awful. Her patient instructions are next to impossible to read and act on, and her prescriptions are easily subject to fulfillment errors. But her EHR experience is so bad that she won't even consider any EHR in her own private practice.
pbug
50%
50%
pbug,
User Rank: Strategist
3/28/2013 | 1:51:16 AM
re: Healthcare Workarounds Expose EHR Flaws
If, as I describe in my comments, the EHR is so slow and so hard to use during a patients visit that she can't take care of the patient and properly record patient data in the EHR at that time, she does the only thing she knows; enters it after her shift is over. Yes, it is beyond absurd security wise that it works outside the hospital (excepting doctors who may need to work remotely), it is equally absurd that a system be so poorly designed and configured, plus the staff so badly trained, that they have to work extra hours to get the data in. It is also painfully common.
Nickname2000
50%
50%
Nickname2000,
User Rank: Apprentice
3/28/2013 | 12:30:22 PM
re: Healthcare Workarounds Expose EHR Flaws
I don't think it is correct to blame the EHR. The EHR did not use guerrilla tactics and jump into the health care organization and install itself. EHR's are supposedly planned, investigated, researched by those in authority. Workflows are to be analyzed. If the EHR cannot take care of what the clinician needs to do, it should be changed PRIOR to implementation, or pick a different EHR. All these articles on "EHR BAD" seem to be written by CEO's or Board of Directors of these organizations, whining that after trying to skip important steps, save money on the short term, ignore clinical work process, etc., it didn't turn out as wonderfully as hoped. No kidding.
jaysimmons
50%
50%
jaysimmons,
User Rank: Apprentice
4/1/2013 | 11:55:54 AM
re: Healthcare Workarounds Expose EHR Flaws
Many of the issues surrounding the EHR should be addressed by management before the EHR gets implemented. When purchasing a product such as an EHR there should be a lot of research and testing performed so providers know they are getting the product that they need. Workflows need to be addressed and the EHR has to be tested to be able to meet the requirements set forth in these workflows. Regarding downtime, which is a big issue as well, providers need to make sure they have servers capable of handling the amount of data and large load associated with running the EHR in their systems.

Jay Simmons
Information Week Contributor
A.Bi
50%
50%
A.Bi,
User Rank: Apprentice
4/2/2013 | 12:48:31 PM
re: Healthcare Workarounds Expose EHR Flaws
Web based EHR can be a great solution for taking notes. Most web based ehr are smart phones/mobile phones enabled, and they store data on the cloud or remote server. Physician or other related person can access from anywhere with Internet enabled device.
Register for InformationWeek Newsletters
White Papers
Current Issue
InformationWeek Tech Digest September 18, 2014
Enterprise social network success starts and ends with integration. Here's how to finally make collaboration click.
Flash Poll
Video
Slideshows
Twitter Feed
InformationWeek Radio
Sponsored Live Streaming Video
Everything You've Been Told About Mobility Is Wrong
Attend this video symposium with Sean Wisdom, Global Director of Mobility Solutions, and learn about how you can harness powerful new products to mobilize your business potential.