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EHR systems pose serious concerns, report says


By Joseph Conn
Posted: June 24, 2013 - 3:00 pm ET
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Electronic health-record systems used in emergency departments are beset with poor data displays, loaded with so many alerts warning of potential patient-safety issues that they can lead to user alert fatigue, and may be generating incorrect physician orders, according to a report by two emergency physicians' study groups.

Meanwhile, providers wanting to address these EHR issues are hampered by a lack of research and solid evidence of the extent of the problem with these systems, and by contract provisions with EHR vendors that stymie the free flow of information about system-linked safety concerns, the report authors say.

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The groups found that “poor data display is a serious problem with many of today's EDISs,” while “the sheer volume” of alerts that range from the “completely irrelevant to life threatening” can “dull the senses, leading to a failure to react to a truly important warning.” They also found that “an alarming number of clinicians are anecdotally reporting a substantial increase in the incidence of wrong order/wrong patient errors while using the computerized physician order entry component of information systems.”

Two study groups from the American College of Emergency Physicians have recommended a program of systemic vigilance over electronic health-record systems used in emergency departments to improve patient safety and enhance quality of care.

ACEP workgroups on informatics and on quality improvement and patient safety published their findings in an article, “Quality and Safety Implications of Emergency Department Information Systems,” in the current issue of the Annals of Emergency Medicine.

It follows in the wake of, and references, an Institute of Medicine report from 2011, “Health IT and Patient Safety: Building Safer Systems for Better Care.” That report concluded that “current market forces are not adequately addressing the potential risks associated with the use of health IT.” It also comes eight months after the New England Journal of Medicine published “Electronic Health Records and National Patient-Safety Goals,” which warned that recent evidence “has highlighted substantial and often unexpected risks resulting from the use of EHRs and other forms of health information technology.”

The ACEP report concludes that “(s)ystem functionality varies greatly” for the electronic health-record systems used in emergency departments, referred to throughout the article as EDISs, whether those systems were home grown, commercial systems specifically designed for EDs—so-called “best of breed” systems—or ED components of multifunctional, multidepartment commercial “enterprise” EHRs.

This variability “affects physician decision-making, clinician workflow, communication, and, ultimately, the overall quality of care and patient safety,” the authors said.

“The rush to capitalize on the huge federal investment of $30 billion for the adoption of electronic medical records led to some unfortunate and unintended consequences, particularly in the unique emergency department environment,” said Dr. Heather L. Farley, the lead author of the report, in a news release. “The irreversible drive toward EDIS implementation should be accompanied by a constant focus on improvement and hazard prevention." Farley is assistant chairwoman of the Department of Emergency Medicine at Christiana Care Health System in Newark, Del.

The authors also report “(t)here are few consistent data on how commonly these errors occur, and few studies are actually focused on collecting evidence of these errors.” Meanwhile, “there is currently no mechanism in place to systematically allow, let alone encourage, users to provide feedback about ongoing safety issues or concerns” with EHRs in general, and EDISs specifically.

The workgroups came up with seven recommendations: appointing an emergency department “clinician champion,” creating within healthcare delivery organizations an EDIS performance improvement group and an ongoing review process, paying timely attention to EDIS-related patient-safety issues raised by the review process, disseminating to the public lessons learned from performance improvement efforts, distributing vendors' product updates in a timely manner to all EDIS users and removing the “hold harmless” and “learned intermediary clauses” from vendor contracts.

“The learned intermediary doctrine implies that the end users (clinicians) are the medical experts and should be able to detect and overcome any fallibility or contributing factor of the product,” the authors said.

They conclude that the “lack of accountability for vendors through hold harmless clauses and the shifting of liability to the clinicians through the learned intermediary doctrine are significant and additional impairments to safety improvement. Electronic health records and EDISs are sufficiently complex that the physician and other users cannot be expected to anticipate unpredictable errors.”

Earlier this month, the Electronic Health Record Association, an EHR developers trade group affiliated with the Chicago-based Healthcare Information and Management Systems Society, announced the launch of a voluntary “code of conduct” in which adherents would agree to drop “gag clauses” in the contracts with their provider customers.

One expert blames at least some of the ED physicians' complaints on the decision of many hospital systems to use a fully integrated enterprise EHR from a single vendor covering all or most hospital departments rather than a complete hospital system built on best-of-breed EHR components from different developers that are specialized for specific hospital departments. That choice of clinical IT strategies has vexed hospital leaders for more than a decade.

Enterprise systems have been in ascendancy recently, and that choice is being reflected in the overall bad feelings reflected in the ACEP report on emergency department systems, said Todd Cozzens, a venture partner and senior adviser at Menlo Park, Calif.-based Sequoia Capital. 

The ACEP authors didn't differentiate between the two in their critical report, saying their recommendations applied to all EHR systems in the ED. 

“These systems do have glitches, but it can be plain and simple bad design that can lead to clinical errors,” Cozzens said.  But ED physicians, he said, are “having the enterprise systems forced upon them. To think you can take one system and adapt it to those different environments is totally wrong. That's why you see low physician satisfaction and the productivity is going down, all for the sacrifice of having an integrated system.” 

Cozzens' assessment was supported by a survey report on physician satisfaction published by Orem, Utah-based health IT market researcher KLAS Enterprises.  KLAS researchers asked more than 130 ED physicians to rate their own EDISs, in a study that looked at products from 12 vendors, eight of which sold enterprise systems and four of which sold “best of breed” specialty EHRs.  

In the overall rankings, the best-of-breed systems swept the top four spots, with scores 59% higher than those using enterprise systems. 

In a subcategory, rating the systems on helping physicians improve quality of patient care, the four specialty EHR vendors also took the top four spots.  In that subcategory, physicians were asked to rate their EDIS on how well it helps them with clinical decision support, avoiding errors affecting patient safety and facilitating communication with fellow care givers in the ED. 

 These ED specialty systems “outperform enterprise offerings relative to improving patient care thanks to intuitive screen/template layouts that reduce order entry errors as well as physician prompts to ask patients more-targeted questions and alert caregivers to adverse drug events,” according to the 216-page report, “Revealing the Physician's Voice.” 

One question from KLAS may tell this story best.  Its researchers received responses from 132 ED physicians to the question: “Where should your vendor focus their EDIS development efforts to best help you?”  

Of physicians using enterprise systems, 75% asked for streamlining of physician workflow and tools, while 14% of enterprise system users picked integration and interoperability as a priority.  In comparison, 36% ED physicians with a best-of-breed system chose workflow improvements, while 52% wanted better integration.

The era of “big data,” which requires integration of data types across various IT systems, including from internal financial systems and outside insurance company data, could change the balance of power in the old debate between best-of-breed versus integrated EHRs, Cozzens said.

“With all that's happening with big data and integration,” he said, “I think you're going to see a resurgence of the specialized systems, because people are getting fed up with the workflow.” 

Follow Joseph Conn on Twitter: @MHJConn


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