Electronic Health Records: First, Do No Harm?

EHRs are commonly promoted as boosting patient safety, but are we all being fooled? InformationWeek Radio investigates.

David F Carr, Editor, InformationWeek Government/Healthcare

June 26, 2014

4 Min Read
(Source: HealthIT.gov)

long after that. "Having a mature EHR system clearly does not eliminate EHR-related safety concerns," they wrote, pointing out that most of the issues they studied could be classified as "unsafe technology" rather than unsafe use of the technology (which would include usability and training issues).

In keeping with Silverstein's point, the report's authors also point out that the VA is unusual among health systems in having an established reporting system for tracking EHR-related safety concerns. "We just don't have similar data from the private sector," lead author Hardeep Singh said in an interview. Singh is a safety researcher at the Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety at Michael E. DeBakey VA Medical Center and at Baylor College of Medicine. Federal regulators require hospitals to gather all sorts of quality data in support of the Meaningful Use program, but "right now, those are mostly focused on getting people to use these systems as opposed to using these systems safely," Singh said.

The best way to respond to EHR safety risks is to track them and learn from them, Singh says. In addition to promoting the adoption of national reporting standards for EHR safety, he worked on the creation of a set of Safer Guides published with the support of the federal Office of the Coordinator for Health IT, which emphasize ways healthcare organizations can enhance their patient safety programs and improve their own performance.

[Learn more and ask your own questions: Tune into InformationWeek Radio's Is Digitizing Healthcare Making It Less Safe?, Tuesday, July 1, at 2 p.m. ET.]

Often, problems can be traced to both computer and human errors. One example, noted in the review of VA data: "a patient was administered a dose of a diuretic that exceeded the prescribed amount. This error occurred due to a number of interacting sociotechnical factors. First, a pharmacist made a data entry error while approving the order for a larger-than-usual amount of diuretic. Although a dose error warning appeared on order entry, this particular warning was known to have a high false positive rate. Owing to diminished user confidence in the warning's reliability, the warning was over-ridden. The over-ride released the incorrect dose for administration by nursing staff. The nurse, unaware of the discrepancy between the prescribed amount and the amount approved by the pharmacist, administered the larger dose."

This isn't a system error per se, except that a feature designed to improve patient safety (the dosage alert) was mistrusted by the staff. Known as "alert fatigue," the issue of excessive and often erroneous alerts is one of the toughest user interface and usability challenges in health IT.

The study identified four main categories of EHR safety hazards:

  • Unmet display needs: The system fails to clearly display the information needed for clinicians to make the right decision.

  • Software modifications: Upgrades, modifications, or configuration errors make the software malfunction.

  • System-to-system interface errors: Failures associated with data exchange between EHRs or between components of the same system.

  • Hidden dependencies in distributed systems: One component of the EHR is unexpectedly or unknowingly affected by the state or condition of another component. For example, the transition of patients between wards or units not reflected in the EHR resulting in missed medications or orders.

While admitting he has probably contributed to some pessimism about the state of the art, Singh believes the net effect of digitizing health records is positive -- or will be, in the long run. "Right now, we're still in a learning process, but there is no going back," he said. On the other hand, the rate at which the government has been pushing for the adoption of health IT is a legitimate cause for concern, he said. "Its rapid pace of implementation jeopardizes things. Most of the vendors who are focused on Meaningful Use and ICD-10 are doing it with systems that were mostly meant for billing," he said.

One of Silverstein's themes is the need to distinguish between the business IT of hospital operations and the requirements of clinical informatics. His advice to hospital CIOs: "Business computing people, who are the people who staff most hospital IT departments, fundamentally need to admit they do not know healthcare. They literally are not qualified to judge good health IT versus bad health IT."

Sounds like an issue worth debating, which is why I invite you to not only tune in but actively participate in our InformationWeek Radio show, Tuesday, July 1, at 2:00 p.m. ET. You'll be able to ask questions through a text chat during the show and after the conclusion of the audio program.

Has meeting regulatory requirements gone from high priority to the only priority for healthcare IT? Read Health IT Priorities: No Breathing Room, an InformationWeek Healthcare digital issue.

About the Author(s)

David F Carr

Editor, InformationWeek Government/Healthcare

David F. Carr oversees InformationWeek's coverage of government and healthcare IT. He previously led coverage of social business and education technologies and continues to contribute in those areas. He is the editor of Social Collaboration for Dummies (Wiley, Oct. 2013) and was the social business track chair for UBM's E2 conference in 2012 and 2013. He is a frequent speaker and panel moderator at industry events. David is a former Technology Editor of Baseline Magazine and Internet World magazine and has freelanced for publications including CIO Magazine, CIO Insight, and Defense Systems. He has also worked as a web consultant and is the author of several WordPress plugins, including Facebook Tab Manager and RSVPMaker. David works from a home office in Coral Springs, Florida. Contact him at [email protected]and follow him at @davidfcarr.

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