Patients can be harmed when there are problems in electronic medical records (EMRs) related to how information is conveyed to other providers and how test results get displayed, according to a recent study.”1
“Suboptimal usability may contribute to safety issues. Providers may be held liable for those issues,” says Jessica Howe, MA, the report’s lead author. Howe is a senior research specialist and system safety specialist at MedStar Health’s National Center for Human Factors in Healthcare in Washington, DC.
Of more than 1.7 million reports of safety issues researchers analyzed, 1,956 indicated the EMR as a cause of patient harm, and 557 reports contained language explicitly suggesting EMR usability contributed to possible patient harm. Of those, 80 caused temporary harm, seven may have caused permanent harm, and two may have been fatal. About 8% of the harm events occurred in the ED.
“It is critical that ED leadership understands that how EMRs are designed, developed, and implemented does contribute to patient harm,” Howe cautions. There is growing recognition that some bad outcomes result from EMRs that were designed or implemented poorly. “We can’t continue to blame providers or ‘user errors’ for these EMR-related harm events,” Howe advises.
In the ED, as in other settings, says Howe, “if the EMR is not designed, developed, implemented, customized, and maintained appropriately, the EMR can promote errors.” Two common ED examples:
- Pending lab results are not detected by ED providers. If there are 11 results and 10 come back, the displayed results do not always show that there is still one result pending. The risk: An ED patient is discharged before an abnormal finding returns.
- Lab results or medications are never ordered because the EP doesn’t realize an additional click is needed. The risk: Delayed care contributing to a bad outcome.
The question “Would any other reasonable provider in the same conditions make the same error?” is the key to determining liability in such cases, Howe explains. “If the answer to this question is ‘yes,’ then this is indicative of suboptimal usability.”
This is one way a plaintiff can bring the hospital into ED malpractice litigation. “If the healthcare system is involved in the customization decisions that impact usability and safety of the EMR at their sites, they could potentially be liable,” Howe notes.
Under certain circumstances, the ED defense team could use a poorly designed EMR to deflect liability away from the EP. However, if the hospital also is named in the lawsuit, the co-defendants likely will be pointing fingers at one another. “That is the plaintiff’s dream,” says Robert B. Takla, MD, MBA, FACEP, medical director and chief of the emergency center at Ascension St. John Hospital in Detroit. Takla offers a better strategy: “Work together on a strategic approach for defense. Even better is to fix the EMR before it causes issues.”
Lorraine Possanza, DPM, JD, MBE, program director for the Partnership for Health IT Patient Safety, curated by ECRI Institute, says these are important issues regarding EMRs in the ED setting:
• The way information looks. For instance, it is not always clear whether lab results are from a current or previous visit.
• How information flows to other providers, both within the hospital and externally. One reported safety event involved a patient admitted from the ED who needed constant supervision due to mental health issues. The ED nurse documented this in the EMR.
“But when the patient went to the floor, that wasn’t readily evident. So no one knew they needed one-on-one supervision,” Possanza says. The patient was unharmed. “But the event demonstrated a concern that information is not always readily visible to those needed to act upon that information,” Possanza adds. Possanza says the main question ED providers should ask is: “Am I communicating information clearly to people who need to know it?”
• Where information is located. Often, ED providers are frustrated because the EMR gives them no easy way to document certain pieces of information. “We still face that free-text issue,” Possanza laments. “If I’m putting something in a free-text area, it’s not necessarily being communicated to the next person. Sometimes, that information is lost.”
It may be that an EP tried to order a medication in a certain dose, but the system only listed six dosages because the drop-down menu only allowed for six boxes.
“The ED provider then has to pick one of the others or free-text it,” Possanza notes.
Possanza says EDs should continually test how information flows. This is especially important after an upgrade or the addition of new modules to see if anything looks different or any information is in a different location. “There are a lot of people who flex in and out of the ED,” Possanza adds. “Maybe they work three days and are then off. They may not have been there the day you did an upgrade.”
It is equally important to encourage ED providers to report problems with the EMR that are affecting patient care adversely. “You want people to tell you when things aren’t working as anticipated. You also need a mechanism so they can learn what was done about the issue,” Possanza offers.
When it comes to user issues with EMRs, says Takla, “Liability will always exist. ‘How can we minimize it by improving the design?’ is the question we should be asking.” ED clinicians and leaders need to work together to modify EMRs to be more user-friendly, Takla says. One example: “nuisance” alerts that ED providers often ignore. This is because the alerts don’t make sense clinically. “They assume they are providing us with a ‘helpful’ alert, but that is not the case. The end result is we ignore them,” Takla notes. Clinical impressions should “pop out” to ED providers, Takla says. Ascension St. John Hospital’s ED has implemented these changes to its EMR based on input from ED providers:
- Request to build mandatory “hard stops” when discharging a patient with abnormal vital signs. This would require the provider to acknowledge any abnormal vitals before discharge. (Takla notes this change was requested, but has not been implemented yet.);
- Critical values are displayed in different colors;
- Eliminate duplicate computerized physician order entry of radiological tests to avoid unnecessary radiation and longer ED length of stay. “This has reduced diagnostic testing by 11%,” Takla reports. If a duplicate test is ordered, the system alerts providers as follows: “This test was conducted on [date], here is the result. Do you want to order it again?”
In some EMRs, the most recent test results always appear at the top of the list. Unfortunately, that’s not true of all EMRs. Further complicating matters, ED providers sometimes work in multiple hospitals. “When they go to find information, it’s not in the same place,” Possanza says. Likewise, allergy information may have a designated location in one record, but no field for entry in another EMR. ED providers are forced to record the information as free text. The bottom line is that every EMR is different, and those differences expose EDs to liability. “The differences multiply when hospitals or medical systems adapt or modify EMRs to fit their specific needs,” says Brandy A. Boone, director of risk resource for ProAssurance Companies in Birmingham, AL.
ED nurses likely are employees of the hospital, whereas EPs often are independent contractors working at multiple health systems. “A major risk in the ED regarding EMRs is lack of consistency in training and use,” Boone notes. ED providers don’t always know where to look for important critical information in the system they are using, such as the most recent test results. Thus, providers lose critical time in providing the appropriate care for patients, delays that can lead to bad outcomes. “When staff develop workarounds and shortcuts within a system, those may not be consistently applied,” Boone adds. “This can threaten the flow of communication.”
Appropriate training is needed for everyone entering or viewing information in the EMR, Boone emphasizes. It is not enough for EDs to establish appropriate usage guidelines for EMRs. “They should also consider how those guidelines are going to be enforced, to ensure more consistent use across the board,” Boone says. Hospitals can do this in these ways:
- For employees, require mandatory training and compliance through orientation and annual performance reviews;
- For non-employed medical staff, through the credentialing process, including initial credentialing and any renewal of privileges.
The idea is to tie compliance to the ability of the medical and nursing staff to continue practicing at the ED. “This can lead to better overall communication, more effective treatment, and more positive patient outcomes,” Boone says.
- Howe JL, Adams KT, Hettinger AZ, Ratwani RM. Electronic health record usability issues and potential contribution to patient harm. JAMA 2018;319:1276-1278.
- Brandy A. Boone, Director, Risk Resource, ProAssurance Companies, Birmingham, AL. Phone: (205) 877-4494. Email: firstname.lastname@example.org.
- Jessica L. Howe, MA, Senior Human Factors Research Specialist, System Safety Specialist, National Center for Human Factors in Healthcare, Washington, DC. Phone: (202) 244-9812. Email: Jessica.L.Howe@MedStar.net.
- Robert B. Takla, MD, MDA, FACEP, Medical Director, Chief, Emergency Center, Ascension St. John Hospital, Detroit. Phone: (313) 343-7398. Email: email@example.com.