EHRs can help you comply with NPSGs
However, authors note that challenges remain
Electronic Health Records, or EHRs, can be valuable tools for quality managers as they strive to comply with The Joint Commission's National Patient Safety Goals. That's a clear message communicated in a recent commentary in JAMA1; however, the authors take care to not only outline some best practices for EHR use, but to also review some of the challenges presented.
Take, for example, patient identification. "Wrong-patient errors occur in virtually all stages of diagnosis and treatment. Reliably identifying individual patients is especially challenging in high-volume practice environments with limited continuity of care,"1 the authors wrote.
"At least once a shift you will not know the patient's name — or the name will not mean anything to you," says one of the authors, Ryan P. Radecki, MD, Department of Emergency Medicine, East Carolina University/Brody School of Medicine, Greenville, NC.
The authors cited a study of ED physicians that used eye tracking, which showed that physicians often fail to adequately confirm the identity of patients prior to order entry. "Eye tracking involves placing a small camera above the top of the computer screen that picks up the pupils and you can see where the eyes are looking — in the case of EHR users, you can see if their eyes look to a particular portion of the screen and you can see if they're performing the desired task or not," Radecki explains.
Naturally, the authors continue, the goal should be for clinicians to reliably identify patients when accessing records and entering orders. What's the best way to do that?
"It's tricky — it really depends on what your interface for the EHR is," says Radecki. "If you put a picture of the patient where you sign the order, or use a different color on the screen, it forces your eye to verify information. Putting it where they're less likely to miss it — like the center of the screen — is as effective as you can be short of forcing someone to do it."
You could enter into your system the requirement to do this before you can sign an order, he continues, but that could add several minutes to each physician's day. "You need balance, so it takes experimentation," he says, adding that highlights, color changes or italics may be used to bring attention to important data such as sound-alike names, patient's initials, date of birth, and so on.
While the authors note that EHRs can enhance test result communication with automatic notifications of the responsible clinicians about abnormal test values, they added that "this alone does not constitute a fail-safe system."1
"One of the problems with putting alert mechanisms into a computer system is you have so many of them and clinical relevance is hard to distinguish," Radecki says, noting that "between 90% and 95% are dismissed and ignored by doctors because they are not well designed or are deemed irrelevant."
For example, he says, there are many medication interactions, but in some the benefits may outweigh the risks. "When you get so many irrelevant alerts you can develop alert fatigue," he cautions, "so if you have a system, it really has to be cautiously defined."
While this constitutes a major area of research, Radecki notes that no solution has yet been found. However, the authors stated, "a fail-safe strategy might be requiring that clinicians acknowledge abnormal test values within a certain time frame (i.e., depending on severity), after which laboratory staff use direct notification."1 Since there is no way to verify that the information has been received if it is not acknowledged, says Radecki, "you might have to fall back on direct communication between providers."
Using meds safely
The authors noted that electronic health records with CDS (Clinical Decision Support) and BCMA (Bar Code Medical Administration) capabilities can significantly improve patient safety. However, they warned, "care must be taken to ensure that all of these interventions fit within clinicians' workflow."1
In addition, they said, BCMA systems need to be implemented both in the pharmacy and at the point of care.
"When fully integrated into the system, a bar code is printed in the pharmacy, affixed to the vial or container that is transported to the bedside and the nurse has a scanner at the bedside to see if there's a match," Radecki explains. "If there is, the patient gets the drugs. Another bar code is on the patient to ensure that the correct patient receives the correct medication or blood product."
One potential challenge here is "workarounds." How do they occur? "Clever nurses, instead of scanning at the patient's wrist, will print out second labels to have at the nurses' station rather than having one on each patient, which defeats the whole purpose," says Radecki. Hospitals have addressed this problem, he adds, by "making it really hard to get second bar codes printed out."
EHRs can also be useful in making sure that staff members are complying with infection control protocols. For example, the authors wrote, "when appropriately configured with easy-to-use targeted checklists, [EHRs] may provide an electronic delivery mechanism."
In addition, they explained, nearly any device can be fitted with software and radio frequency identification (RFID) transmission capabilities so that checklist monitoring can take place in real time via the EHR. "For example, if you want 100% compliance in hand-washing, you can put a transmitter on the dispenser, and if a staff member's RFID tag goes near it without registering, you can tell that staff member isn't washing their hands," says Radecki.
Similar checklists may be used to assess suicide risk, he continues. "This is challenging, but you can force the EHR to prompt people at registration to ask certain questions," says Radecki. "You can also program it to look for words like 'sad,' 'depressed,' or 'quiet,' and conduct a quick screening."
"As with all computer-based interventions, incorporation of EHRs into routine clinical workflow is critical; their effectiveness depends on appropriate maintenance, effective user training, periodic institutional self-assessment of EHR safety and effectiveness, and clinically focused policies to support their use," the authors concluded.1
- Radecki RP, Sittig, DF. Application of Electronic Health Records to the Joint Commission's 2011 National Patient Safety Goals. JAMA 2011;306(1):92-93.
[For additional information, contact: Ryan P. Radecki, MD, Department of Emergency Medicine, East Carolina University/Brody School of Medicine, 2100 Stantonsburg Rd., Greenville, NC 27834. E-mail: firstname.lastname@example.org.]