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Noting that too many errors related to health information technology (HIT) are resulting in adverse consequences, The Joint Commission (TJC) has issued a Sentinel Event Alert, urging health care providers to take steps to improve their safety culture, approach to process improvement, and leadership in this area. In this latest alert, the accrediting agency is taking particular aim at risks posed by sociotechnical factors – or the ways in which HIT is implemented and used. Experts say that many of these risks are, in fact, exemplified at a higher level in the emergency setting, where providers are under constant pressure to see more patients and move them though the system faster.
It’s no secret that for all of the efficiencies that health information technology (HIT) brings to the table, there are also immense challenges that go along with safely using tools that, in many cases, alter workflow, documentation, and the way providers interact with patients. Of particular concern is the potential for patient harm that can result when systems are poorly designed or implemented, raising the possibility that information will be miscommunicated or entered incorrectly.
Indeed, in an analysis of 3,375 sentinel events that resulted in permanent patient harm or death between January 1, 2010, and June 20, 2013, The Joint Commission (TJC) found 120 events that included HIT-related contributing factors. For this reason, TJC has issued a Sentinel Event Alert, urging health care providers to take steps to improve their safety culture, approach to process improvement, and leadership in ways that will effectively address the risks posed by the rapid entry of new HIT tools into the health care setting.
While TJC has sounded the alarm about HIT before, this latest alert focuses particularly on the risks posed by sociotechnical factors. Experts agree that while these types of issues are complex, the need for new solutions is clear. “The technology is only as good as the processes and people that you have to implement it,” notes Shaun Grannis, MD, MS, the associate director of the Regenstrief Center for Biomedical Informatics in Indianapolis, IN. “I do think the sociotechnical factors are a substantial portion of the issues we need to face here.”
The ED is hardly immune to these issues. In fact, the emergency environment is brimming with opportunities for HIT-related errors to occur, according to Drew Fuller, MD, MPH, FACEP, the director of safety innovation for Emergency Medicine Associates in Germantown, MD. “If we thought about the factors that contribute to errors in the environment in health care, they are exemplified at a higher level in emergency care on a daily basis, he says. “In the ED, we have to multi-task. I have 10 patients at one time, and I have to manage all of their care at the same time, and there is no other way to do it.”
Fuller adds that production pressures are higher in the ED than in other settings, and there are competitive pressures as well. “Everybody wants to be the best ED group or the best ED, and there is more and more pressure to move patients [through] faster,” he says.
Further, whereas most specialists take care of a very thin and selective slice of the health care burden, Fuller observes that the ED takes care of it all “from the newborn who is struggling to breathe to the 90-year-old who is having sudden stroke symptoms to the 45-year-old with chest pain,” he says. “[Emergency providers] take care of all patients no matter what age, no matter what conditions; they have to cover like 24 different specialties, and this in addition to the noise, chaos, and other factors that play a role.”
For all of these reasons, Fuller notes that even some of the best-run EDs in the country are at highest risk for factors that can lead to lapses in communication, cognitive errors, oversights, and any lapses that can lead to harmful events.
Many of the problems cited by TJC in the Sentinel Event Alert relate to orders or medicines being prescribed for the wrong patients. These can result from toggling errors or pop-up screens where providers are asked to click on the appropriate patient or medicine, and they mistakenly click on the wrong selection.
Other problems can result from poor data displays — an issue that is probably as challenging as it has ever been, notes Fuller, who reported on this and other HIT-related problems in a 2013 article.1 “I used to be able to look at a paper chart and know in a very short period of time what was going on with a patient because everything was very succinct and clean and there wasn’t a lot of text that got repeated,” he explains. “What used to be a two- or three-page chart has become a 10- or 15-page or even a 20-page chart that we have to scroll and scroll and scroll through.” The sheer volume of text makes it harder for abnormal findings to stand out, he adds.
However, Fuller acknowledges that EMRs do offer a lot of value in certain, select areas — especially retrospective value, when clinicians are trying to look back and see what was done on a patient hours, days, or weeks earlier. “They have a lot of value there, but in real time, [EMRs] sometimes make it harder for us to communicate between teams,” he observes.
To make such systems work better, it is important to acknowledge that EMRs are difficult to use and that they can increase communication barriers, advises Fuller. “There needs to be additional pathways formalized in which the physicians and the nurses can communicate,” he says.
For example, in his own workplace at Calvert Memorial Hospital in Prince Fredrick, MD, clinical leaders are starting to mandate that physicians seek out the nurse and share the plan of care with him or her after they see a patient, or share key information regarding transitions of care, explains Fuller. “The reason why it is … important to make those policies within your department now is because the EMR is so consuming that it has put up a wall between the physicians and the nurses. If you go into an ED now you see a bunch of people with their faces stuck in a computer,” he explains. “We think having a code of expectations where we can make communication more formalized is going to help with that.”
Grannis notes that one of the challenges he has faced as an informatician is that he has to bridge multiple cultures. “I bridge the technical, I bridge the process, and I bridge the clinical, and often those are different skill sets within an organization,” he says. “All of those people who don’t talk or collaborate as much as they potentially need to now come together and realize, gosh, the IT folks aren’t just doing scheduling and billing for us anymore. They’re actually supporting systems that impact patient care and we need to understand that.”
Similarly, the workflow people who are setting up processes for care and medication delivery need to be communicating with the IT people. “It has to be collaborative, and I think that is a fundamental point that I bring away from this,” adds Grannis. “Often I think with health IT there is almost this mistaken assumption that it is all about the technology, when, in fact, I think it is all about the humans who implement, manage, and use that technology.”
In the ED specifically, Fuller recommends the establishment of a multidisciplinary performance improvement group to continuously monitor the ED information system (EDIS), recognize problems, and work with the vendor to resolve them. “We have a core physician champion, nursing leadership, and IT people working together with the vendor to make modifications in the system to help make it work better with the workflow,” he says.
There is also a mechanism in place by which IT problems can be quickly and easily reported. “My hospital has a phone line where you can actually leave a voice message to the nurse champion who actually does the modifications,” notes Fuller. “It doesn’t mean that every concern is easily addressed, but the point is it needs to be quick and it needs to be easy because we know physicians won’t use formalized electronic reporting systems. There is just natural resistance to that.”
Robert Wears, MD, MS, PhD, FACEP, a professor in the Department of Emergency Medicine at the University of Florida (UF) Health Science Center in Jacksonville, FL, and a core faculty member for the fellowship in patient safety and quality at UF, recommends that hospitals and EDs arrange for usability assessments before making purchasing decisions about health IT. “This involves more than just showing a system to users and asking them if they like it. There is a formal engineering process that you can go through to look at the usability of systems,” he explains. “The problem is that the people with the skills to do this are not real common.”
Also, Wears advises ED directors to press their hospital administrations hard for a commitment to rapid cycle change. “When [new IT systems] go into place that haven’t been well-designed, that is when all kinds of problems are going to pop up right off the bat,” he explains. “The last thing you want is the organization saying that it is because you aren’t trained very well. What [administrators] should be saying is they will fix that for you right away, so if they will commit to doing [rapid cycle change], then I think you can get rid of the worst [IT-related problems] right away.”
Many of the IT-related issues that crop up are minor, but when they create obstacles for staff, the issues can turn into bigger problems, observes Wears. “Fixing things like this very quickly without a lot of running around is a very important way of getting people to support the system,” he says.
For instance, Wears notes that the IT system used by the Veterans Administration is old and clunky, but a lot of people like it because it is home-grown. “They actually have an office of software safety, so when an issue comes up, they don’t get all this finger-pointing,” he says.
In fact, Wears suggests that one of the biggest problems with the software systems now in place at most hospitals is that they are not required to have any sort of safety assessment. “That is astounding when you think about it,” he says. “You can’t write a program for flight management software and install it on airliners without having a safety assessment of the program that is approved by the FAA [Federal Aviation Administration], so that is one of the fundamental things that needs to be changed [in health care].”
An added challenge is that many software vendor contracts have clauses that spare them from any financial responsibility when design problems lead to adverse consequences, explains Fuller. Some contracts even prevent clinicians from publically pointing out or discussing software problems that have been identified in specific programs, he says. “The auto industry doesn’t have these rights, so we have asked that those [provisions] not be part of clauses [in software contracts],” observes Fuller.
While the convergence of so many different types of health IT has created a complex landscape, there are a number of tools that health care administrators can leverage to help them monitor the systems they have in place and identify opportunities for quality improvement. For example, TJC recommends that hospitals make use of the Safer Guides for EHRs, offered by the Office of the National Coordinator for Health Information Technology (www.healthit.gov/safer/safer-guides).
“I think [the Safer Guides] provide a great framework for thinking through a number of these issues, from technical things like system interfaces to system configuration, patient identification, and workflow-related issues like clinician communication and processes for monitoring and follow-up,” notes Grannis. “[The Joint Commission’s] sentinel event alert evaluation form also provides some very clear areas to be addressed.” (www.jointcommission.org/safe_health_it.aspx)
Grannis explains that while most of these documents provide strategic bullet points, they still need added details to be filled out underneath, and these will vary depending on the complex business practices and workflows of each individual organization. “This is an emerging space,” he says. “I think we will get better at identifying the kinds of patterns that lead to both good and not so good, or suboptimal outcomes, and we have to recognize those patterns quickly and address them but, again, we are talking about very complex interactions among multiple stakeholders. The frameworks that have been put out there will help us begin to do a better job of that, but I think we have an opportunity to improve.”