Sloppy EHR Implementation Could Threaten Patient Safety

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A study of health IT implementation at seven Department of Veterans Affairs (VA) hospitals shows that when information systems are implemented without proper planning and management, problems can occur and threaten patient safety. These problems are not unique to VA hospitals, and other institutions will undoubtedly encounter them as they roll out their own electronic health records.

Published in the American Journal of Managed Care, the study was based on interviews with nurses, pharmacists, physicians, IT staff members, and managers. The interviews were conducted several years after the introduction of the VA's computerized patient record system (CPRS) and bar code medication administration (BCMA) system.

Those implementing of both systems encountered a number of difficulties in the VA hospitals. Many staff members were not familiar with computers, and the new systems disrupted their workflow. There were also differences among the institutions in how much buy-in they got from clinicians and how responsive management was to the problems of front-line staff.

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Whereas CPRS was gradually phased in over time under the overall direction of the VA administration, BCMA came in much more abruptly, and staff members at individual hospitals had to figure out how to implement this system on their own.

The hospitals also were allowed to select their own computer hardware. Some of them had difficulty deciding how many computer terminals they needed. Because they use computer carts, hospitals required wireless systems, but some did not sufficiently test these systems before implementing their CPRS and BCMA.

In some hospitals, network problems slowed down computer response time, and dead spots in some places led to interruptions in coverage. Eventually, the situation improved as these technical problems were rectified.

According to the study, during the first months of BCMA implementation "every site had problems with medications being miscoded, items not scanning, and empty unit-dose packages being delivered to the wards… Most sites reported difficulties with patient wristbands; at many sites, nurses would cut the bands off patients’ wrists to scan them, or scan from extra wristbands in the patients’ charts. At some VA hospitals, staff were implicitly or explicitly permitted to use various workarounds with BCMA, such as typing codes directly into the computer or doing all scanning after medication administration."

Researchers noted that in some sites these workarounds persisted even years later, despite technical upgrades that fixed most of the problems with BCMA.

Peter Kilbridge, MD, senior research director, healthcare IT suite, for the Advisory Board Co., told InformationWeek Healthcare he was not surprised by the VA study's findings because most of them have already been documented in the literature. "The take-home lesson is that if you take a complex project and are not very careful, you can screw it up, and that can have an impact on patient safety."

Kilbridge noted that BCMA is especially difficult to implement. "BCMA gets into nurses' faces much more than clinical documentation or other EHR tasks," he said. "Medication administration has always been part of their autonomous area. [Nurses are] the ones who give the medications. And now you're getting in their face when you change their workflow, as you do with BCMA. So it's not surprising that it raises a higher level of anxiety than EHR implementation does."

Another major challenge for all hospitals, Kilbridge added, is the need to bar-code unit doses of medications, which don't come into the hospital that way.

HIMSS Analytics, which grades hospitals on how far they've progressed along the EHR spectrum, places BCMA in stage 5 of its 7-stage taxonomy. According to the research firm's latest figures, 8.4% of hospitals are in this stage; another 6.4% of hospitals are in stages 6 or 7.

The VA study points out that the time demands of BCMA on nurses were very high at first, and other studies have shown a degradation in their communications with physicians and patients. Yet there was no budget to put on additional nurses.

"You've got to anticipate that that's going to happen, and share that in a frank dialog with your nursing managers," said Kilbridge. In addition, he noted, it's always a mistake to monitor nurses' productivity at this stage because if they're monitored, they'll emphasize bar coding over patient care.

In every health IT implementation, he added, there are always unanticipated consequences, regardless of how good the planning is. "So expect the unintended consequences and plan for resolving them in an above-board, candid, and productive process," Kilbridge advised.

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