Dean Sittig, Ph.D., a leading expert on clinical decision support tools, and Ryan Radecki, MD, argue that if particular features were added to inpatient EHRs, hospitals would more easily be able to achieve the Joint Commission's safety goals. This year, the NPSG priorities for hospital quality improvement initiatives include patient identification, staff communication, medication labeling, infection control practices, medication reconciliation and interactions, and mitigation of suicide risks.
The commentary points out that both the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) are pushing the safety agenda very hard right now. CMS recently announced its $1 billion Partnership for Patients safety program, designed to reduce hospital-acquired conditions and readmissions.
Sittig and Radecki have some very specific recommendations for how to use clinical decision support (CDS) to achieve the 2011 NPSGs. Here are some of them:
Patient identification. EHRs should require clinicians to enter a patient's initials or their date of birth before order completion, because doctors frequently fail to adequately confirm a patient's identity before they sign orders. In addition, bar-code medication administration (BCMA) systems should be used in hospital pharmacies and at the point of care to ensure that patients receive the proper medications or blood products.
Staff communication. Current EHRs include automatic alerts to ensure that abnormal test results are brought to physicians' attention right away. But the authors say that isn't enough because of interruptions and "alert fatigue." They suggest requiring clinicians to acknowledge these alerts within a certain time frame.
Safe use of medications. The application of "contextual CDS" within computerized physician order entry, along with BCMA, can help assure that the right patient gets the right dose of the right medication at the right time. In addition, the authors caution that all of these tools must fit into clinical workflow, or they'll be ignored.
Infection prevention. EHRs can be used both to reduce overall infection rates and to track the spread of multi-drug-resistant organisms. Checklists can also be helpful in improving compliance with infection control behavior, Sittig and Radecki note. Interestingly, they don't mention infection surveillance software.
Medication reconciliation. The use of EHRs to reduce the risk from duplicate medications and drug interactions is the best example of how the NPSGs might be aligned with Meaningful Use, the authors say. But systems must be interoperable to help clinicians compile meaningful, up-to-date medication lists.
Suicide risk. EHRs offer several possibilities for identifying patients at risk of suicide, including checklists and routine screening for depression.
The authors caution that, even if EHRs contain the recommended features, the incorporation of these components into clinical workflow and the proper training of clinicians are essential to improve patient safety.
EHR vendors support Sittig and Radecki's concept. "The essence of what they're talking about is where most progressive EHRs are headed today," said Charlie Jarvis, vice president of healthcare services and government relations for NextGen, and vice chair of the EHR Association.
The EHR Association also has no objections to including safety features in MU and EHR certification criteria, Jarvis said. "Once you agree on a program [of safety enhancements], that's the logical way to go. We need a standard mechanism for comparing products. As stage 1 of Meaningful Use has shown, Meaningful Use is a good mechanism, so we should go in that direction."
But EHRs should not be overloaded with features that make them difficult to use, he added. "We have to review these things in a detailed way and make sure that we're not boiling the ocean to get at a little bit of seaweed."
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