EHR Usability Linked to Possible Patient Harms, Study Finds

The usability and interoperability of electronic health records (EHRs) has long been a source of frustration for healthcare providers, but until now, specific usability issues and EHR processes that may contribute to possible patient harm have not been identified. A new analysis has discovered that patient safety reports that mentioned a specific EHR by name found some mentions of language suggesting the EHR may have contributed to possible patient harm.

The study, published in JAMA Tuesday, examined patient safety reports from 2013 through 2016 from 571 healthcare facilities in Pennsylvania and from a large mid-Atlantic multi-hospital academic healthcare system.

Of 1.735 million reported safety events, 1956 (0.11%) explicitly mentioned an EHR vendor or product and were reported as possible patient harm and 557 (0.03%) had language explicitly suggesting that EHR usability contributed to possible patient harm.

However, the actual numbers are probably underestimated, said the lead researcher, Raj M. Ratwani, PhD, MA.

“We specifically looked at electronic health record usability, which is really the extent to which a clinician can safely, efficiently, effectively, and satisfactorily use an electronic health record or any technology for that matter,” said Ratwani, who is acting center director and scientific director of the National Center for Human Factors in Healthcare, part of MedStar Health.

The main takeaway for the healthcare industry “is that some electronic health records suffer from poor usability and this poor usability is associated with patient harm events.”

“We should not be tolerating anything that's going to cause harm, but it's also important to highlight that we took a very, very conservative approach in the way that we analyzed these data,” he said.

There are 3 reasons why the numbers are likely higher, he said. For one thing, the data mostly come from Pennsylvania and 1 health system outside of it. He said he would expect the rates to increase if the analysis were scaled across all 50 states.

Second, the study only looked at reports that explicitly mentioned the name of a vendor or a product. But in their day-to-day work, Ratwani said, clinicians do not usually include the names of EHR vendors or products when they write up patient safety reports.

The third point is that patient safety events are known to be underreported compared with the actual number of events that happen in a clinical setting, by as much as a 5- or 10-fold difference, he said.

Of those 557 reports, the majority (84%) fell into a category where they potentially required monitoring to preclude harm, 14% potentially caused temporary harm, 1% potentially caused permanent harm, and fewer than 1% could have required intervention to sustain life or could have resulted in death (n = 2).

Examples included occurrences like:

• An allergy alert did not fire to the prescriber even though the allergy was listed in the EHR (a usability issue categorized under alerting).
• Tests ordered by the physician were not performed because there was a confusing translation between the physician order and the EHR (a usability issue categorized under workflow support).
• A patient was given an additional dose of medication (a clinical process issue categorized under medication administration).

To help solve this issue, both vendors and providers have to work together, Ratwani said. He also said that, in the past, sometimes EHR providers have spent a lot of time focused on the design of the job or the process to be captured within their product, and what gets left out is the fact that the healthcare organization that is adopting the EHR is making changes to the final configuration on their end during the implementation phase.

He said they could “potentially be making decisions that are undoing some of the great usability choices and safety choices by the vendor. So we really need to focus on the variability that's occurring during implementation and ensuring that vendors and providers are working together to address these challenges.”

Second, he said, there should be a focus on fine-tuning the policies that are in place guiding the usability and safety of EHRs, specifically as 2 critical pieces of the 21st Century Cures Act are rolled out and implemented over the next several months. One, he said, is a section that has to do with making usability transparent and not blocked by EHR vendors and other stakeholders.

The second has to do with conducting “real-world testing” of EHRs, he said.

The third piece is having a strong health information technology collaborative in place to identify gaps and prioritize challenges, Ratwani said. He pointed to the National Coordinator for Health Information Technology and the Health Information Technology Advisory Committee, of which he is a member, as one forum in which to work on these issues.

Reference

Howe JL, Adams KT, Hettinger AZ, Ratwani RM. Electronic health record usability issues and potential contribution to patient harm. JAMA. 2018;319(12):1276-1278. doi: 10.1001/jama.2018.1171.