A look at unintended consequences of EHRs
By Lou Ann Wiedemann, February 2012
The industry needs to focus on building EHRs that decrease medical errors and enhance patient care.
Achieving high-quality, cost-effective care requires an integrated healthcare delivery system that includes hospitals, providers, specialists and, in some cases, long-term care. Navigating this continuum of care can be fraught with twists and turns that are confusing to patients and their care providers. Medical errors, hospital-acquired conditions, rapid implementation of electronic health records (EHRs), fragmented delivery systems and technology constraints are just a few of the many issues affecting healthcare quality and patient safety today.
In this healthcare environment, evidence of patient harm may not be glaringly obvious. For example, the interface between a laboratory system and EHR cannot be visualized by the healthcare provider. If high lab results indicating a myocardial infarction are not integrated into the EHR, thus notifying the clinical care providers immediately, several hours may pass before the patient’s symptoms are treated. As a part of continuous efforts to improve healthcare, most providers and organizations are investing large sums of capital dollars in health information technology.
While there is some reasonable evidence that EHRs can reduce patient safety issues, we must remember that the EHR has also introduced a whole new category of events that cannot be ignored in the rush to implementation. The healthcare industry needs to begin focusing on building EHRs that decrease medical errors and enhance patient care.
The cost of medical errors
Medical errors contribute to a significant loss of healthcare funds each year; the costs are often staggering. According to findings commissioned by the Society of Actuaries (SOA), measurable medical errors cost the U.S. $19.5 billion in 2008. This report demonstrates an opportunity for the healthcare industry to increase quality and patient safety. In addition, the report demonstrates a need for decreasing the cost of healthcare and increasing efficiencies in the continuum of care.
Since 2008, there has been no shortage of statistics indicating patient safety concerns and the cost of errors. Despite massive attempts to measure patient safety and increase quality of care, the Agency for Healthcare Research and Quality (AHRQ) reported in 2007 that patient safety improves at just 1 percent per year.
EHRs have been promoted as the key ingredient to better care coordination, a decrease in healthcare costs and improvements in efficiencies. However, realizing all of these benefits is often more difficult than expected. As organizations and providers continue to invest heavily in EHRs and health information technology (IT), there is an increased need to see the benefits of these systems.
In recognition of the continued challenges associated with using EHRs, AHRQ funded additional research to identify the unintended consequences of EHRs. The results of the research culminated in a guide designed to assist organizations and providers in anticipating potential problems associated with EHR implementations.
AHRQ defines unintended consequences as an unanticipated and undesired effect of implementing and using an EHR. These unintended consequences include increased work for clinicians, unanticipated workflow changes and repeat requests for system changes or upgrades. As these consequences occur, end users become frustrated with the system and software. As frustration levels grow, end users begin to develop workarounds or revert back to paper processes.
For example, a hospital has an electronic lab system that reports abnormal lab values. The physician prints out the lab report and adds handwritten remarks to the report. This handwritten information is not a part of the electronic version of the lab report and contains important clinical information. How does the organization incorporate the changes into the health record?
Another example: An organization has implemented computerized physician order entry (CPOE). Upon entering orders for a patient, the physician may be prompted to answer questions, such as, “Should the patient have nothing by mouth prior to the study?” In the past, these types of questions were answered by the clerk as the order was entered. The physician becomes frustrated with the prompts for information and reverts back to writing a paper order. He passes his paper order to the nurse, who then hands off the orders to the clerk who then enters the order into the system. The physician may have solved one problem, but he has created another. Now the order that the clerk entered has to be signed by the physician.
Both of the examples above can create additional risks to patient care and often negate the benefits of the EHR. The EHR processes were intended to speed up communication between care providers and the ability to provide patients with care (e.g., medication or x-rays). Because of frustration with the system and increased time to enter information, the EHR becomes a dreaded tool. The clinical care providers see the EHR as a tool that increases their time and effort and does not meet their needs; this does not promote trust that the system will assist them in doing their jobs. These unintended consequences must be addressed in order to reap the full benefits of the EHR.
Paper-based processes are not the only unintended consequences seen with EHR implementations. Other unanticipated results may occur when multiple systems are expected to interface with each other. What happens when the lab system does not interface with the EHR, or the interface is not working properly? For example, a patient’s lab report indicates a dramatically low potassium level. The information does not file in the EHR, or files in the wrong record. The physician does not know the level is low, misses writing an order for IV potassium and the patient suffers a heart attack.
The same type of issue can occur in the radiology system, pharmacy system or other modules expected to file reports or interface with the EHR. Monitoring the interface alone is not enough. If the organization knows that the report did not interface, it will take a manual entry to file the report, which is time consuming.
If the report files to the incorrect chart, it is almost impossible to detect. The interface worked correctly; it is not going to show up on a “reject” report. And yet, incorrect information is in the patient’s chart, and care providers are making decisions based off that information.
AHRQ further recommends that those utilizing EHRs should thoroughly understand the causes of their EHR problems in order to proceed with developing a corrective action plan. The guide also provides guidance on prioritization. Organizations or providers can review a series of factors that will assist them in identifying and prioritizing their unintended consequences. Refer to AHIMA’s article, “Unintended Consequences: Identifying and Mitigating Unanticipated Issues in EHR Use,” for more information on AHRQ’s report, recommendations and case studies.
Building better systems
The healthcare industry must begin to build better systems that address and promote patient safety and quality. The Institute of Medicine (IOM) reported in November 2011, “When designed and used appropriately, health IT is expected to help improve the performance of health professionals, reduce operation/administrative costs and enhance patient safety.”
In IOM’s report, “Health IT and Patient Safety: Building Safer Systems for Better Care,” the committee found that literature and reports of EHRs and patient safety were inconclusive. While some specific applications are successful in improving care, some case reports agree with AHRQ that some systems create new and unanticipated risks.
The report does suggest that a systems approach to implementation may increase patient safety. The implementation of EHRs involves many moving parts, such as clinical care providers, patients, registration, technology and organizational-specific issues. All of these moving parts create a complex healthcare delivery system. In order to build a better system, IOM suggests that developing a user-centered design approach is needed.
This approach would include appropriate and adequate testing and quality-assurance assessments. The final product should provide end users with the ability to receive and retrieve accurate, timely and reliable patient data. The report also calls for the Department of Health and Human Services (HHS) to develop new measures that will assess health IT safety and monitor for improvements.
Although EHRs may decrease some patient safety initiatives, there is no doubt that they also create many new risks. In AHIMA’s practice brief, “HIM Functions in Healthcare Quality and Patient Safety,” we outline the critical functions health information-management professionals perform in the delivery of safe, high-quality patient care. Utilizing the existing data within the health record can provide the necessary information to improve patient safety practices. Failure to understand these issues can increase risks to quality care and patient safety. Is it time to implement mandatory reporting of EHR events? Should HHS be responsible for overseeing these events and monitoring both the systems and organizations that have them? There is no doubt that in order to receive the ultimate benefits of an EHR, these issues must be addressed. As EHRs are rapidly implemented to meet the imposed deadlines of 2015, consideration of these issues must be taken into account.
Lou Ann Wiedemann, M.S., RHIA, FAHIMA, CPEHR, is a director of professional practice, AHIMA.