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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 infor- mation and reverts

Lou Ann Wiedemann, M.S., RHIA, FAHIMA, CPEHR, is director of professional practice, AHIMA.

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 communi- cation 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 do- ing 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 im- possible 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 prioriti- zation. 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 sys- tems 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: Build- ing Safer Systems for Better Care,” the committee found that literature and reports of EHRs and patient safety were inconclusive. While some specifi c applications are success- ful 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 imple- mentation 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 or- der 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 prod- uct 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.


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