Addressing poor EHR usability, data errors, and a lack of healthcare interoperability are key ways providers can ensure patient safety.
Patient safety is an ongoing epidemic that healthcare organizations, stakeholders, and EHR vendors are trying to fix. However, it is an expensive and complicated task that starts with EHR usability and extends to interoperability.
In a study conducted by MedStar Health National Center for Human Factors, researchers found that roughly 40 percent of EHRs reported having an issue that can potentially lead to patient harm. About 786 hospitals and 37,365 individual providers may have also used EHRs with potential safety issues based on required product use reporting.
“Oftentimes when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence.
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“In reality, it’s a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it’s customized, and how it’s configured.”
Fixing EHR usability is an important way to improve patient safety and although it may be a burden to health systems, furthering healthcare interoperability is also a way to prevent potential harm.
Improving data integrity
Direct patient safety issues can happen when EHR products that are not designed, developed, or implemented at a high standard. A cluttered interface or a complex medication list are two common usability concerns that can lead to potential patient safety events.
For example, a particular EHR system that Ratwani and his team analyzed in their recent study removed the decimal point when a provider keyed in a medication dose.
“If a physician were to type in an order for 2.5 milligrams of a medication, what would actually be entered and processed by the EHR is 25 milligrams,” Ratwani said. “This could lead to a significant overdose. Those are the kinds of issues that were occurring.”
EHR users need the data entry process to be as clean as possible. Consistent data input is also key, Ratwani explained.
“There may be instances where the patient is weighed in pounds, but the information needs to be entered into the EHR in kilograms and their unit may be unclear in the interface,” said Ratwani. “We’ve seen instances where height and weight may be mixed up on the interface because of poorly designed EHRs. The overall principle here is simplicity and ensuring that there’s consistency there, laboring of information and all of it’s tied to the way data is entered.”
A second major data integrity issue is the copy and paste tool in EHRs. National Institute of Standards and Technology (NIST) recently highlighted this issue in an EHR usability study.
“‘Copy and paste’ functionality is intended to allow medical practitioners to easily and efficiently reuse information in patient EHRs without having to retype the information,” the study stated. “However, in practice, current implementation of this functionality has introduced overwhelming and unintended safety-related issues into the clinical environment.”
Copy and pasting is a sensible functionality that cuts time and cognitive burden for clinicians. However, it comes with consequences, such as potential patient safety issues.
Not only did the study find that the function impacts situational awareness due to large amounts of medical information being moved around the EHR, but it also uncovered frequent problem involving the wrong information being moved within the document. Researchers explained that users failed to review and edit the information because the EHR system did not offer an efficient editing platform.
Healthcare organizations and EHR vendors need to address the EHR usability factor to ensure EHR data integrity and patient safety.
EHR Reporting Program
Ratwani and the Office of the National Coordinator for Health Information Technology (ONC) believe that an EHR reporting program, which was mandated by the 21st Century Cures Act, has the potential to make EHR usability improvements and further protect patient safety.
“There’s a reporting program for medical device issues and a reporting program for vaccines and for medications,” he explained. “We need the same thing for health information technology so that when a clinician or even a patient sees potential safety issues, there’s a central reporting program where they can report this issue and then people can rapidly analyze those and communicate that information out to the community.”
The EHR reporting program asks EHR developers to submit data on the functions of their health IT products, thus contributing to the establishment of new EHR certification requirements. Gaining feedback and information from the stakeholders is the next phase of EHR reporting program development and it will allow the ONC to prioritize patient safety.
In an effort to improve EHR usability and safety, Congress tasked the ONC with gathering information on security, interoperability, usability, and EHR design. In return, the ONC will release the draft measures publicly on their website in 2020. The reporting program’s goal to hold EHR developers accountable and drives transparency.
Partnering with the Urban Institute to build the program, the ONC has received feedback from stakeholders, including physicians, nurses, and children’s hospitals. The respondents called for more information on how usability can impact patient safety. EHR usability differs from each user and problems with the EHR can lead to medical errors and clinician burden.
This feedback is key to improving the usability and safety of EHR use, Pew explained in a post. With this data, organizations can address the issues and learn more about other EHR vendors.
To make an EHR reporting program possible, Ratwani and the ONC believe gag clauses need to be eliminated from vendor contracts.
“Gag clauses prevent clinicians from openly sharing screenshots and other information on their EHR products,” Ratwani said. “Without being able to share that, we wouldn’t be able to actually identify these issues very broadly.”
Healthcare interoperability, or lack thereof
Participating in health information exchanges and accessing the technology can be a disruptive and expensive task for health systems.
Yet, Intermountain Healthcare CMIO Stan Huff, MD believes that healthcare organizations that agree to those two steps will likely see improvements in patient safety, specifically with the ongoing opioid epidemic.
“There are a large number of applications or clinical decision support that you can imagine could be applied to opioids,” Huff told EHRIntelligence.com. “Programs could help clinicians create the correct dose of the medication and choose the correct opioid for the task or review the clinical situation to say whether an opioid was necessary, or whether you can get by with anti-inflammatory drugs or Tylenol.”
But the differences between health IT systems is a major obstacle to putting these systems into action.
“To use those systems, developers would have to write a program for literally every enterprise or facility that was trying to implement that kind of knowledge. But interoperability would allow that to be scaled,” he said.
Endorsing application programming interfaces (APIs) that leverage Fast Healthcare Interoperability Resources (FHIR) to store and access data related to opioids, developers would only need to write clinical decision support programs once.
“The program could run anywhere that the system was compliant with FHIR standards,” said Huff.
Huff believes that improving the way opioids are prescribed will ultimately make the pricy and disruptive investments in healthcare interoperability well worth it.
“Becoming compliant with interoperability is a lot of work,” said Huff. “At the same time, that work is one hundredth or one thousandth of the work of recreating every clinical decision support program at every facility.”
With effective interoperability, healthcare stakeholders would be able to “
“Scale those kinds of programs as executable knowledge as opposed to a written protocol that somebody then has to implement and make into software and write a program for at every single facility that wants to do that,” he explained.
Widespread interoperability would help providers exchange data regarding opioid use and confirm the notion that safe opioid prescribing practices is a top priority for healthcare organizations.
Overall, improving EHR usability and furthering interoperability holds the keys to cutting down on the constant and critical issue that is patient safety.
Source: EHR Intelligence