This post has been updated with comments from William Marella, ECRI Institute executive director of Patient Safety Organization Operations and Analytics and Lorraine Possanza, ECRI Institute program director, Partnership for Health IT Patient Safety.
The steep learning curve the healthcare industry faces in adopting new technology combined with the wide adoption and implementation of electronic health records have made EHR issues a regular feature on ECRI Institute’s annual top 10 list for patient safety concerns. The list highlights healthcare technologies associated with the most adverse events or, more frequently, near misses jeopardizing patient safety and what can be done about them.
This year, information management in EHRs made it to the number one spot on the top 10 list, according to an ECRI news release. The development suggests there’s an urgent need for better training on these EHR systems or at least make it easier for the correct information to be entered and viewed.
Information management in EHRs is a pretty broad category, but ECRI Institute’s William Marella said it’s at the heart of many of the adverse events the institute has seen. Marella, the executive director of Patient Safety Organization Operations and Analytics, said in an emailed response to questions.
“When clinicians don’t have access to complete information, or when the information isn’t timely, or it’s inaccurate, it can have real consequences on the quality of care a patient receives. For example, we’ve seen cases where allergies are listed in the header of the EHR, but the space only accommodates one or two allergies, while others are visible in a pop-up window only if the user hovers over that space. We’ve seen cases where drugs are listed in a drop-down pick list, and the names are truncated so the user doesn’t know if they’re ordering a standard formulation or an extended release version.”
Marella offered another example from the report — a drug overdose.
“The patient’s current weight wasn’t available to the pharmacist because the interface from the EHR to the pharmacy system was pulling from a field that wasn’t updated. It could also be because the info was not updated or was not visible.”
The report recommends having members of health IT management and health IT workers play a bigger role in patient safety, quality, and risk management programs. Other strategies include encouraging staff who use the EMR system to report concerns.
Lorraine Possanza, an ECRI Institute senior patient safety, risk, and quality analyst and health IT patient safety liaison, noted in the report that it’s not enough for hospital staff to know how to use the EHR system. They need to know what it is capable of.
Do users know which information is available to them? Do they know which information transfers to other systems? Do they rely on information in the record? Do users know what to expect—for example, do they know whether the most recent lab result appears at the top or bottom of the list?
Marella noted that better system testing of hospitals’ EHR systems could avoid many of the adverse events he cited in the report but this but unfortunately this often isn’t treated as a priority due to resource constraints.
The goal of EHRs — to make it easier to share patient records and identify patient’s needs — is also what has the potential to create pitfalls when the wrong patient information is entered. Health information needs to be clear, accurate, up to date, readily available, and easily accessible, the report said.
Clinical decision support is supposed to guide care teams to make better choices for the patient’s benefit, but if a system produces too many alerts, or don’t produce that insight when it is needed, that can undermine the effectiveness pof these products.
The report recommended that a multidisciplinary team of healthcare professionals oversee CDS to ensure that users have the training they need and that the system is tested properly.
Also, since each healthcare facility is different, these multidisciplinary teams should also address basic questions such as when CDS alerts are triggered, the patients this should be used for and other critical factors controlling the use of this tool.
Another issue that should be considered: Should the CDS alert be structured so that providers need to do something before they can proceed?
Asked in an email to share her thoughts on what hospitals should look out for regarding EMR implementation, Possanza cautioned institutions not to use EMR and EHR interchangeably.
“The EMR is the limited record that was typically limited to one practice setting, and the EHR is the record that becomes available in multiple settings—the hospital, the ambulatory setting, the long-term setting, for health information exchanges and for patient portals. Best practices include understanding and using your system to its capacity, using the tools that are available to you.”
Other concerns outlined in ECRI’s list include:
- Unrecognized patient deterioration;
- Test result reporting and follow-up;
- Antimicrobial stewardship;
- Patient identification;
- Opioid administration and monitoring in acute care;
- Behavioral health issues in nonbehavioral health settings;
- Management of new oral anticoagulants;
- Inadequate organization systems or processes to improve safety and quality.
Although these reports are aimed at hospitals, I hope healthcare startups are paying attention, because this list of pain points in healthcare settings and what needs to be done to improve them is exactly the kind of insight they should be applying to their businesses.
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