When Dean Sittig moved to Houston, he, like most drivers, was very comfortable merging to the left to get on the highway. But Houston's seven-lane freeways often require merging to the right. "I wasn't good at merging to the right, and I knew I had to be careful, especially if I was crossing multiple lanes," he says. Even after several years, he still exercises extra caution.
Sittig, professor of biomedical informatics at the University of Texas Health Science Center and a leading researcher on hazards in clinical information systems, says that with the rapid adoption of electronic health records, clinicians nationwide are having to learn to "merge to the right." They have to record and use information in unfamiliar ways that create new opportunities to make mistakes, and Sittig says extra training will go only so far.
"Most wrecks aren't caused by lack of driving skill," he says. "We don't re-train drivers after they have a wreck-we just tell them to be more careful." Most clinicians have the basic computing skills they need, but the "be more careful" part will take longer to internalize, and will need a team effort by vendors, provider I.T. staff and users.
While experts generally agree that electronic health records are better for patient safety than paper ones, there's growing recognition that they present their own challenges. In its annual round-up of top 10 medical technology hazards, ECRI Institute, Plymouth Meeting, Pa., ranked "data integrity failures in EHRs and other health IT systems" No. 4, with several other IT-related hazards also on the list.
ECRI senior patient safety analyst Erin Sparnon says hazards most often occur because of some misalignment between the system configuration and clinician workflows. Faulty programming or implementation can lead the systems to behave unexpectedly, and inadequate training has clinicians unprepared for how new I.T. will change the way they work.
For example, Sparnon recently published an analysis of 324 EHR errors reported to the Pennsylvania Patient Safety Authority that were connected with incorrect default values for medication order sets.
While none of them harmed patients, they easily could have. In some cases, a default "stop" order canceled an antibiotic a physician wanted to have continued. In others, patients missed a medication because the order entry system assigned the task by default to a staff member whose workflow hadn't been modified to include it. One out of five of the errors occurred because the default dose value didn't match what the clinician had ordered, and the ordering system gave priority to the default dose.
Another ECRI study of 511 chemotherapy order sets showed that one in 10 had been recommended for removal or consolidation, and all the others had at least one change based on the most current best-practice information. "Hospitals need to make sure they have a policy of requiring regular review and update," Sparnon says. "Knowledge about medications changes all the time, and new medications come in. Any standard order sets should reflect the most current thinking."
Machines and people
Sittig puts HIT hazards into two broad categories. In the first, the technology itself misbehaves somehow; in the second, the technology is doing what it's supposed to, more or less, but is a bad fit with the user's needs and habits.
Sometimes bugs are obvious. At St. Vincent Hospital, Erie, Pa., an interface between the HIS and the pharmacy dropped a crucial bit of information-which patients were pregnant or lactating. "That information is of supreme importance to make sure there are no adverse events," because any medications can affect both mother and child, says Lidia Giles, IT director of clinical applications. Her department quickly instituted a workaround that involved paging the pharmacy whenever a pregnant or lactating patient was admitted, and Giles says the defect has been corrected in the version of the software currently being installed.
Another system upgrade unexpectedly changed the appearance of a report, so that discontinued medications were no longer highlighted with a gray bar. "Users were used to seeing this very nice, clearly evident bar, and we had to educate them to look for the date and time stamp instead," Giles says. "During upgrades, so many pieces are changing that it's easy to take away something good." The vendor eventually showed the staff how to restore the look everyone was used to, but it was a confusing few days.
Susan Boisvert, senior clinical risk management consultant for malpractice insurer Coverys, Boston, recommends that end users be notified about all system upgrades and other software changes, no matter how minor the IT department believes those changes to be. "Everyone should be on the alert," she says. For example, an upgrade can accidentally cancel things like automatic antibiotic stops, leaving patients on a medication for too long.
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Interfaces are another treacherous point. Even when they're working perfectly, Sittig says they often drop key information by design. "There's a lot of pushback on the size of the buffer," he says. "I think I'm sending 100 characters, but you only accept 75, so it gets truncated at the beginning or the end. Until you know others are having the same problem, you think you've made a mistake."