Healthcare Workarounds Expose EHR Flaws

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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.

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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.