Becker's Hospital Review

112 Chuck Lauer R ecently I was on a conference call ar- ranged to learn from three nationally recognized healthcare CEOs about how their respective organizations were faring under reform and other changes facing the industry. What jumped out at me was their unanimous re- action when asked about their electronic health records systems. Words such as "unwieldy," "cum- bersome" and "unhappy" were used to explain how each of them felt about their EHRs. If I could add a few words, they were "sold a bill of goods." The big IT vendors are seen as inattentive, hav- ing shifted on to the next multimillion-dollar sale. "When you ask them to help, they charge outlandish fees," one CEO said. Another added, "They don't really seem to care." The third said: "My physicians are not happy" with the system. Some of the other participants on the call didn't seem surprised by all the negativity displayed by the CEOs. As one put it: "This frustration has been building for some time." In February the Premier hospital alliance pub- lished results of an online survey of its members. More than 40 percent of respondents, the major- ity of whom were CEOs, CFOs and COOs of in- tegrated delivery networks, said they were either indifferent to or dissatisfied with their current EHR systems. It's clear that at a crucial time for the industry — which is faced with declining reimbursement, consumer-driven care, a shift toward value and meaningful use penalties — information technol- ogy has become more of a problem than a solu- tion. It goes much deeper than problems with service. A report in the Journal of the American Medical In- formatics Association found the EHRs pose a seri- ous threat to patient safety. Researchers evaluated 100 closed safety investigations reported between August 2009 and May 2013 to the Informatics Pa- tient Safety Office of the Veterans Health Admin- istration. Among the findings were 74 events that resulted from unsafe technology, such as system failures, computer glitches, false alarms and "hid- den dependencies," a term for what happens when a change in one part of a system inadvertently leads to key changes in another part. Another 25 events involved unsafe use of technology such as an input error or misinterpretation of a display. Here is a case study of what can happen because of EHR complexities, which cover various dimen- sions including software interface and workflow communications: A pharmacist makes a data en- try error apparently inputting a higher dose of a diuretic than what was prescribed. A warning ap- pears, but this kind of warning has a high false- positive rate. Consequently, the pharmacist has poor confidence in the warning's reliability, and the warning is ignored. Of course, the incorrect dosage is sent to the nurse, who was never made aware of the discrepancy. Study author Hardeep Singh, MD, a safety re- searcher at the Center for Innovations in Qual- ity, Effectiveness and Safety at the Michael E. DeBakey Veterans Affairs Medical Center and as- sociate professor in the department of medicine at Baylor College of Medicine, made it clear that the issue is "not just the technological complex- ity, it's also the social aspect around technology. We're just now beginning to get an understanding of this." The VA has maintained a voluntary reporting system to investigate EHR-associated adverse events since 1999, which the study authors said provided the infrastructure to collect data. Even after the system had been in place for years, er- rors continued unabated. Dr. Singh believes this is a reminder of why it is important to be proac- tive about monitoring EHR-related issues. Many health systems are focused intensely on meeting meaningful use and ICD-10 rules instead of rig- orously evaluating what these new systems might mean for patient safety and clinical outcomes. We have, of course, been down this road before. Medical technology is adopted as a reaction to some external stimuli such as competition, regu- lation or publicity surrounding a medical error. Effort is expended to finance, acquire and roll out the technology, but then everyone assumes it is doing what it is expected to do and moves on to the next problem. Taking good care of patients is supposed to healthcare's Job 1, and patient safety is a big part of that. We assume a good EHR aids in this pro- cess, but assumptions aren't enough in medicine. Many other patient safety experts have also noted the complexities of introducing new technol- ogy into already complicated healthcare environ- ments. In a recent patient safety virtual conference, Deborah Simmons, the senior vice-president and chief quality officer of St. Luke's Episcopal Health System in Houston, cited other counterproduc- tive features in EHRs, such as drop-down menus that are too narrow to allow users to see all of the information they need and want, or medication lists so long that a clinician cannot find a drug he or she is seeking. Such negative features may seem trivial but it's a "huge deal" because "It's incredibly important to make it very clear, so clinicians get the informa- tion without any ambiguous extras as they go through their work day," Ms. Simmons said. As hospitals move to integrate electronic records systems with other systems, they should keep in mind the potential complications associated with, for example, connecting the order entry to the patient's medication record to the pharmacy system. "If you make a change in one part of the system, it's like dominoes falling down. It affects everything, and the more complexities built into the system, the more difficult it is to trace," Ms. Simmons said. Taking care of patients is a very complicated busi- ness and with the advent of EHRs and other IT tools, it has been made even more complicated and sophisticated. We must continue to study, evaluate and refine these systems, especially when it involves patient safety. And IT vendors need to stop worrying about the next sale and step up to the plate to help current customers realize at least part of the promise of electronic health records. n EHRs Seem Like More of a Problem Than a Solution By Chuck Lauer, Former Publisher of Modern Healthcare and Author, Public Speaker and Career Coach Words such as 'unwieldy,' 'cumbersome' and 'unhappy' were used to explain how each of them felt about their EHRs.

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