Electronic health-record systems are doing a poor job graphing lab-test results, conclude the authors of an article published online in the Journal of the American Medical Informatics Association.
The authors of “Graphical Display of Diagnostic Test Results in Electronic Health Records: A Comparison of 8 Systems,” call on the Office of the National Coordinator for Health Information Technology at HHS to impose more stringent requirements in developing future rounds of EHR testing and certification criteria under the EHR incentive payment program “to ensure a clear and accurate visual display of lab data.”
“The results were not overly surprising,” Seth Teigen, regional vice president, ancillary services for SSM Health Care of Wisconsin, said after reviewing a draft copy of the research article.
But the results represent a serious problem, said Teigen, whose work at SSM Health Care includes overseeing the integration of lab and radiology systems across his organization. “Allowing for such a wide variation in how test results like this are reported and displayed sets our caregivers up to fail, and can ultimately impact patient safety,” he said.
None of the eight systems studied escaped the slash of the researchers' red pens when scored against 11 criteria selected “for optimal graphs based on literature and expert opinion.” One system missed only one criterion. Three systems met only five of 11, a grade of 45%.
“We still haven't even figured out how to label graphs correctly in a uniform fashion across EHRs,” said co-author Dean Sittig, professor at University of Texas School of Biomedical Informatics, Houston. The graphing problems represent “sort of a small anecdote in a larger story,” namely the lack of standards across healthcare IT development, Sittig said.
Seven of the EHR systems tested are in widespread use by hundreds of thousands of healthcare providers.
Six have been tested and certified under a process developed by the ONC for use in the federal EHR certification program. They are from developers Allscripts Healthcare Solutions, Cerner Corp., eClinicalWorks, Epic Systems, Meditech and Partners Longitudinal Medical Record. A seventh system is the Veteran Affairs Department's Computerized Patient Record System, the clinician-facing module of the VA's largely self-developed VistA EHR.
The remaining system reviewed, Glassomics, is a Web-based EHR prototype, designed to work with Google Glass, and “an example of what people are calling the 'new breed' of EHRs,” Sittig said. Systems were not rated by name in the report, however.
Graphs on all eight systems had the same elementary omission—failing to label the vertical, or Y-axis—an omission that would make many freshman algebra students' eyes roll and earn a red mark from their teachers.
“Graphs are an easy thing where people will agree that the X and Y axes ought to be labeled,” Sittig said. “That's not a stretch.”
A more egregious flaw was an abnormality in how the passage of time was graphically represented by one EHR—from right to left across the horizontal or X-access—instead of the common depiction of left to right.
As a consequence, for this outlier EHR, lab results for Hgb A1C, which is commonly used to measure and help maintain blood glucose levels of diabetics, were represented as increasing over time by a line rising from right to left.
For the seven other EHRs, however, their graphs with a similar slope would indicate falling Hgb A1C levels.
Another EHR system depicted the time across the X-axis in unevenly spaced increments, another potential patient safety risk because it could distort perceptions derived from the slopes between data points.
“When you're going between different patients and different EHRs, and one of them is not evenly spaced and this one is evenly space, you missed that sense of time,” said Dr. Hardeep Singh, patient-safety researcher at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston. “That could cause a problem.”
The latest study adds to nearly a decade's worth of research that points to an uncomfortable truth: Health information technology sometimes can create patient-safety issues.
Problems with displays are compounded by the pressures applied to providers in recent years to rapidly adopt and use health information technology, said veteran physician informaticist Dr. William Bria. As a result, a number of EHR systems have been configured and implemented in a rushed, “unexpert, inelegant manner,” Bria said.
Physicians, too, are under increased pressure, and are “moving at a faster rate of speed,” said Bria, executive vice president of medical informatics and patient safety at the College of Health Information Management Executives and chairman of the advisory board of the Association of Medical Directors of Information Systems.
Speed increases the risk to a physician from non-standardized, incomplete presentations of data such that important information “may go past them,” Bria said.
“It is the current workflow that makes the rectification of this kind of problem much more important than it might have been, say, 10 years ago,” Bria said.
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