Peer-reviewed journals and blogs are full of articles nowadays lamenting the electronic health record (EHR). This isn’t surprising, given the Gartner Hype Cycle’s view of technology adoption. It doesn’t take long to realize we are currently in what Gartner calls the “trough of disillusionment,” when interest wanes as unintended consequences of implementation come to light. Now, there are emerging concerns that health information technology (IT) might be harming patients and burning out health care professionals.
So what do we recommend? We realize that the deeply rooted policies, billing, and documentation issues in current EHRs cause much frustration and aren’t going away anytime soon, but we must ensure that we are delivering safe care. For EHR users and health care organizations (HCOs) implementing them, it’s time to do some of the things we discuss here to improve safety. While we are waiting for vendors to improve their products, and for health policymakers and regulators to address EHR burden and data-entry requirements, we propose next steps to help us share responsibility for safer EHR-enabled patient care.
We have described three types of health IT safety issues that users and HCOs should be aware of. They represent a range of risks and opportunities for health IT to influence patient safety.
First, health IT must be safe, and we need to find and reduce safety concerns that are unique to technology, such as ridding health IT hardware and software of defects and malfunctions. An unsafe EHR situation might involve a system crashing, or a clinician’s computer suggesting the wrong medication dose.
Second, health IT must be used safely. That is, there should be safe, appropriate, and comprehensive use of technology by clinicians, staff, and patients, and we should identify and reduce unsafe changes in workflows that often emerge after a new technology is introduced. Examples are copying/pasting information no longer true (or just incorrect) and inadvertently signing auto-populated information that is clearly abnormal. Unsafe use might also include a physician overlooking an important abnormal lab or medication interaction alert in the midst of several inconsequential alerts, or duplicate orders being cancelled by two separate people.
Third, we should use technology to improve safety, to identify and monitor patient safety events, risks, and hazards, and to intervene before harm occurs. A well-designed EHR system has the potential to improve medication ordering (e.g., by identifying the most appropriate antibiotic based on patient and hospital characteristics) and strengthen coordination among a patient’s multiple providers, among other benefits. It’s important to remember that we need to ensure the first two — safe IT and safe use — before we can begin to use IT to improve patient safety.
Many EHR issues are not hard to fix, as long as you can communicate them to the right people in your health system and collaborate to address them. Here are some ways to do that.
Start with Safety Huddles
In an article in the Journal of the American Medical Informatics Association, we describe how one midsized hospital used safety huddles to learn about safety concerns related to its EHR. Huddles occurred every morning, lasted about 20–30 minutes, were led by hospital leadership, and included representatives from clinical, information technology, and administrative departments. Discussions involved safety issues that had transpired over the last 24 hours and what might go wrong in the next 24.
While some HCOs are conducting daily huddles about patient safety concerns, this one also addressed various types of EHR issues, such as software or hardware problems, loss or delay of data in transmission, or errors in data display. Because the hospital had just opened its doors and implemented a new EHR, the leadership’s goal was to bring people together to identify and solve the complex health IT–related challenges they were all facing. Responsible parties were assigned to ensure these issues were addressed.
Our study of daily huddle notes spanning 249 days found that safety huddles facilitated open communication across teams and specialties, raised situational awareness of EHR-related safety problems, and encouraged a blame-free culture, which is essential for users to speak up. Safety huddles greatly increase the “collective mindfulness” of an organization. We recommend that all health systems consider establishing them.
Beyond Huddles: Individuals
Huddling should be a metaphor for sharing information about safety concerns. Users must speak up about EHR safety issues in more than one way, and if your HCO is not doing huddles, find another good way to report them. Unfortunately, most clinicians do not report health IT problems, and when they do, they often do not get a satisfactory response. Existing reporting systems need substantive investment to capture health IT issues more effectively. It’s also hard for many users to conceptualize the depth of the problem.
To increase your impact, you might get actively involved in one or two committees that make EHR-related decisions in your organization, and/or take the free educational module on EHR safety offered by the Joint Commission. Everyone in an HCO who works with EHRs should consider taking this course.
Beyond Huddles: Organizations
To enable better understanding of safety issues related to health IT, we recommend using a sociotechnical model that describes technology-related and “social” dimensions of an EHR-supported health care system. In our recent analysis of data from huddles, we used six of the model’s eight dimensions to classify EHR safety concerns, from hardware and software to workflow and communication (see box); two dimensions weren’t relevant to this study. Each of these is an area virtually any EHR user can relate to. This sociotechnical approach is also outlined in the 2015 Joint Commission Sentinel Event Alert.
Sociotechnical Dimensions Used to Analyze EHR-Related Safety Concerns
1. Hardware and software (the computing infrastructure used to power, support, and operate clinical applications and devices)
2. Clinical content (the text, numeric data, and images that constitute the language of clinical applications)
3. Human-computer interface (all aspects of technology that users can see, touch, or hear as they interact with it)
4. People (everyone who interacts in some way with technology, including developers, users, IT personnel, informatics specialists, and patients)
5. Workflow and communication (processes to ensure that patient care is carried out effectively)
6. Internal organizational features (policies, procedures, work environment, and culture)
Shared Responsibility Principles
One thing is clear from our recent studies and the sociotechnical approach: to ensure patient safety, we need shared responsibility between EHR vendors and those responsible for configuring, implementing, and using EHRs. Two ideas: include representative/s from the health IT department in your organization’s EHR safety huddles, and incorporate language about shared responsibility for patient safety in contracts with health IT vendors.
It’s equally important to put into place a long-term health IT safety program to continuously analyze reported incidents. Our review of reported events at the U.S. Department of Veterans Affairs, a pioneering user of EHRs, reveals that despite highly sophisticated technology and close monitoring, EHR-related safety concerns are still seen long after “go-live.” Thus, improving the way an EHR functions needs constant organizational attention.
Many providers and HCOs don’t realize that when these systems are implemented, there’s a long maintenance, or optimization, phase — and that along the way, they need to track data and make sure staff are fixing problems when they occur. For example, a recent analysis involving 14 sites using several different commercially available EHRs found that errors associated with clinical decision support systems continue to arise well after implementation. Reasons include the introduction of new concepts or codes by the laboratory or pharmacy, inadvertent disabling of alerts, and incorrect reuse of clinical condition codes (e.g., those used to identify different forms of coronary artery disease).
In addition to these approaches, there are other ways of “huddling up” to help improve your EHR experience. All HCOs should consider using the Safety Assurance Factors for EHR Resilience (a.k.a. SAFER) Guides from the Office of the National Coordinator for Health Information Technology to bring together different EHR stakeholders to establish a safety-related plan of action.
We developed and then recently revised these nine guides to help organizations evaluate their EHRs, identify vulnerabilities, and create solutions to lessen risk. Each guide provides 10–25 recommendations for actively assessing potential hazards related to both EHR infrastructure and high-risk clinical processes. SAFER Guides include tips for both vendors and HCOs. Clinical users are encouraged to participate in SAFER assessments, and organizations should support their involvement.
Rights and Responsibilities
Lastly, in an effort to promote discussion and shared responsibility between EHR developers and users, we previously identified 10 high-priority areas that, if addressed, could overcome some existing challenges. We organized these as “rights and responsibilities” for EHR use, among them the right to succinct patient summaries and to ample training and assistance. The goal is to lay a foundation upon which EHR designers, developers, implementers, policymakers and — most importantly — users of health information technologies can work together to build a new age of EHR-enabled and enhanced health care.
EHR developers have made tremendous technological progress over the past 50 years. To reach the next level of EHR-enabled care innovation, we must have substantial collaboration between EHR developers and clinicians on both technical and sociological issues, many of which affect patient safety. We hope the recommendations in this article will inspire these diverse communities of professionals to communicate more openly and share responsibility for safer EHR-enabled care. Only then can we use EHRs to drive improvements in the quality and safety of patient care.