Recent research may not tell the whole story about electronic health records (EHRs) and patient safety, says Rich Temple, vice president and chief information officer at Deborah Heart and Lung Center in Browns Mills, NJ, and an Alliance Partner of the Cleveland Clinic Heart, Vascular & Thoracic Institute.
“To some extent, I question the premise that EHRs have not meaningfully contributed to patient safety. I believe they really have been transformative in supporting the drive toward safety catalyzed by the Institute of Medicine’s To Err is Human report,” he says. “While, clearly, EHRs are still a work in progress as they continue to evolve to address safety needs, I believe the biggest possible benefits accrue to those who are more mature users of EHR technology.”
Hospitals must be vigilant in weighing the benefits of using clinical decision support (CDS) tools in EHRs against the potential downsides of overly tying doctors to their computers with an abundance of manual, perceived non-value-added tasks, Temple says.
Research indicates CDS testing over the course of 10 years, at an aggregate level, has contributed to an improvement in patient safety, Temple notes. “And, strikingly, it shows a dramatic improvement over the course of the last couple of years, as hospitals became more facile with EHRs and as additional tools for interoperability have been introduced and improved upon,” he says. “When you dive into the analyses in more detail and evaluate the more detailed forms of CDS, some demonstrate dramatic improvements, and others, not nearly so much.”
An important consideration is that CDS is not offered in a vacuum, Temple says. Workflow and configuration decisions loom large in facilitating an EHR’s success in driving patient safety. Doctors often bypass alerts they deem to be “noise.” If there are too many of these alerts, the CDS poses a risk of “alert fatigue,” which can lead to bypassing important alerts, he says.
In this scenario, because there are so many alerts, they all just get tuned out. Going beyond merely CDS alerts, it is essential for provider institutions to strike the appropriate balance between rigorously displaying CDS alerts and not presenting an overly burdensome documentation regimen to the provider, which comes with the short-term risk of distracting from face-to-face care and the longer-term risk of physician burnout, he says.
“It also bears noting that the capture of the necessary building blocks for effective CDS — medications, allergies, and problems — is a perennial challenge in healthcare institutions. For instance, who performs the initial data entry for these? Who verifies the data entered?” Temple asks. “While, typically, physicians are the first-line custodians of problems, medications and allergies are often entered by patient care technicians or medical assistants who don’t have the depth of expertise on specific doses or routes of different medications and could be prone to erroneously entering vital medication or allergy information.”
Even when they are pulling data in from external sources, such as Dr. First or Surescripts, there often is a “translation” from the nomenclature used by the external pharmacy data to that required by the EHR, Temple says. This is another opportunity for error.
“The maintenance of patient problem lists is a tribulation all unto itself. Problems come and go, and their relative importance directly correlates to what the patient’s specific encounter is for, which can cause confusion and throw off the CDS algorithms baked into the EHR,” he says. “A problem that should have been deactivated but wasn’t can contribute to fallacious or even dangerous alerts; hence, the incredible importance of maintaining the problem list, which is cumbersome and time-consuming for providers already under stress from the day-to-day pressures of providing excellent patient care.”
Another consequence and challenge of the movement to interoperate electronic data across provider care settings is that a glut of external information that may not be current or relevant can gum up the works of the CDS process, Temple says. The industry has come a long way in ability to paint a full picture of a patient’s medical history across care setting. But Temple says the downside is that you can dilute the incremental value of the external information if you are loading too much into the record. You place an extra burden on physicians to take time to review data that may have no pertinence to the issue at hand.
Temple endorses the recommendation that providers share safety assessments with EHR vendors to help provide visibility into how CDS can be improved, noting regulations are pending that will open the door to facilitate this type of collaboration.
“The fact that there is significant variation on safety scores across different users of the same EHR speaks to how important process, culture, and workflow are in maximizing the safety potential of any EHR. The technology is generally there; the configuration of the technology and the people, process, and culture are the critical variables in success in utilizing an EHR platform to achieve clinical excellence,” Temple says. “It can be done with the appropriate and unceasing commitment to doing it right.”
- Rich Temple, Vice President and Chief Information Officer, Deborah Heart and Lung Center, Browns Mills, NJ. Phone: (609) 621-2080.