EHRs Linked to Errors, Harm, AMA Says

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A new AMA report on patient safety in ambulatory care finds that safety problems are widespread but that little is known about which problems cause the most harm. Among the uncertainties cited by the AMA researchers is the contribution of electronic health records (EHRs) to patient safety.

"The use of electronic health records has the potential to improve patient safety and early research shows some promise, but these systems have also been linked to errors and harm," the report says. "It is not yet clear how many providers will adopt these systems, nor the extent to which health IT will improve patient safety in ambulatory care versus generating new types of errors."

The report cites studies indicating that EHRs encourage providers to "copy and paste" clinical data and that they support "automatic behavior" rather than careful reasoning and analysis. Poorly designed systems with hard-to-use interfaces, data entry errors, and software configuration issues can also endanger patients, the report noted.

David Classen, MD, a consultant to the AMA on the report, told InformationWeek Healthcare that the researchers took no position on EHRs, pro or con.

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"That study was looking at the evidence from a scientific point of view and finding there is still very limited evidence that EHRs improve the safety of care in the average doctor's office," noted Classen, who is also a CSC consultant and an associate professor of medicine at the University of Utah School of Medicine.

Most safety studies, Classen pointed out, have been conducted in large healthcare systems and academic medical centers. That's true, for example, of studies showing the positive effects of electronic prescribing and test ordering in ambulatory care settings. "So we really don't know what's going on in the regular physician's office."

A recent Institute of Medicine (IOM) report called on the Department of Health and Human Services (HHS) to work with the private sector to assess the impact of health IT on patient safety and to lower the risks posed by the technology. If this approach didn't work after a year, the IOM suggested, the Food and Drug Administration (FDA) should help HHS develop a framework to regulate health IT, including EHRs and health information exchanges.

Ironically, despite EHRs' drawbacks in patient care, they appear to be essential for measuring the kinds of safety problems that the AMA report addresses, including incorrect prescribing, misdiagnoses, and failure to act on abnormal test results. And measurement is key to improvement.

"Performance improvement in the future will be electronic, because the ability and the time and cost and resources to conduct such studies without EHRs will probably become prohibitive," Classen noted.

In a recent paper in the New England Journal of Medicine, Classen and coauthor Ashish Jha advocated including measures of adverse events in the Meaningful Use criteria and requiring certified EHRs to have modules for documenting those events. If such data were pooled, Classen said in the IW interview, EHRs could help measure the extent of medical errors in ambulatory care.

In a commentary on the AMA study in the Journal of the American Medical Association, Classen and Matthew Wynia, MD, lead author of the study, proposed several ways to jump-start improvements in this area. They suggested these steps:

-- Conduct a national study to measure patient safety issues in ambulatory care.

-- Set an achievable goal, such as reducing the number of abnormal test results that aren't followed up in a timely manner.

-- Engage patients and families in the improvement of ambulatory-care safety.

-- Improve transitions of care between inpatient and outpatient settings, partly through mechanisms such as medication reconciliation.

-- Build "safety networks" of ambulatory care practices to explore methods of improving patient safety.

According to Classen, "everything we asked for in the commentary could be facilitated by EHRs more easily" than if practices used paper records. But it would be possible, though expensive, to measure ambulatory-care safety deficits by reviewing paper charts, he added.

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