EHR Design Flaws Contribute to Patient Harm in the ED

From June 26, 2013 Article from HealthLeaders Media

Errors in patient care, attributed to electronic health record systems used in emergency departments, are “incredibly common,” says a researcher. But vendor contracts prevent physicians from speaking publicly about problems with the systems.

Patients are being subjected to treatment mistakes and harm because of design problems in electronic health record systems now being rolled out in the nation’s emergency rooms. But emergency department doctors are powerless to correct these flaws because of gag clauses that prohibit them from publicizing the issues.

Those are among several key findings in a report released Monday by 15 members of an American College of Emergency Physicians [PDF] panel who say hospital administrators have rushed to buy systems from major EHR vendors to get incentive payments without considering the ED.

When inpatient systems are introduced to different emergency room processes, emergency physicians’ input is not sought in advance, leading to major functional problems impeding good care.

Asked if emergency room electronic health record errors cause frequent errors in patient care and even harm, Jesse Pines, MD, Office for Clinical Practice Innovation director at George Washington University and the report’s senior author, replied:

“Based on anecdote, it’s incredibly common… If you ask any ED provider if they’ve had any of these events happen in the last six months, my guess is that universally, it will be rare to find someone who hasn’t seen an issue, a near miss or actual error that’s occurred.”

The problem with quantifying such events, Pines says, is that “the way the vendor contracts are set up, they do not allow the users to really speak publicly about their individual system…to expose any of these issues. So one of the recommendations of this panel was to take these clauses out of these contracts.”

“It doesn’t promote patient safety if you can’t talk about it. And if you do something that changes the EHR in a good way, you should be able to publish that so it can be disseminated to other systems.”

The silence has prevented quantification of the problems that might provoke the vendors to make their systems more foolproof, Pines says.

Kevin Baumlin, MD, vice chair of the emergency department and director of informatics at Mount Sinai Hospital in New York who is a member of the ACEP panel, emphasized that there’s no question electronic health records have improved healthcare.

In one example, clinical decision support at his hospital has “saved 70 lives” of patients with severe sepsis, simply by triggering earlier recognition of the problem and thus, earlier rescue.

“But the reason why we’re going through this process (installing EHR systems) is to reduce our errors, not make more of them. We wrote this article to say, ‘Hey, let’s be careful we’re not creating a whole different set of errors while we’re getting rid of old errors and error types.”

The report outlines four types of “pitfalls” commonly seen in EHR systems and makes seven recommendations to address the issues.

1. Communication Failure

A physician may enter into the electronic record an order that he or she already gave the nurse verbally, thereby inadvertently giving the patient more than the intended dose. The report gives this example:

“The loud moaning draws you into room 10, where you find a patient rocking back and forth, holding his right flank. ‘He says it is his kidney stones,’ informs the nurse. After a cursory examination, you ask the nurse to give him 1 mg of hydromorphone to ease his obvious discomfort. You then receive an urgent request to reevaluate a critical patient. Finally, you sit down at a computer station to chart and enter orders for the patient with a presumed kidney stone.

“Half an hour later, you check in on the patient and he is difficult to arouse. ‘How many milligrams of hydromorphone did the patient get?’ you inquire. The nurse tells you 3 doses of 1 mg each. ‘How did that happen?’

“Well, you remember you asked me to give 1 mg of hydromorphone while we spoke in the room, then you ordered another 1 mg in computerized physician order entry with an as needed order for a third.”

2. Poor data display

The report says most vendor products list the results in tabular or text format, requiring the physician “to scroll through long tables or lists of results.” While some abnormal results are often in bold, in red, or underlined, it’s tough for the clinician to distinguish the truly abnormal results from those that are less important.

“It’s 10:30 p.m., admitted patients have been stacking up in the ED since the day before, and there is no relief in sight from the crowding. You have 27 patients in your section of the ED, and more than half have results pending from various imaging and laboratory studies. You are waiting for a few critical laboratory values on your sickest patients, and you are scrolling through the “Results” section on the new EDIS.

“You try to review laboratory results for many of your patients quickly and click a button to “accept all” results, which enters the results into individual patient charts. In doing so, you miss an elevated troponin level for a patient who was admitted for a cardiac evaluation.”

3. Wrong order/wrong patient error

“You are caring for several patients and have just left the room of an agitated 34-year-old woman who is withdrawing from alcohol. You go to your computer, open the patient tracker, and intend to order 2 mg of intravenous lorazepam for the patient. While in the process of preparing to enter the order, you are interrupted to ‘sign’ an ECG of a 65-year-old man with chest pain who has just arrived by ambulance.

“You are concerned about a possible ST-segment elevation myocardial infarction, so you hurriedly enter the order for lorazepam and proceed to go

to the room of the chest pain patient. The lorazepam order is inadvertently entered on another patient, an 80-year-old with congestive heart failure, who is also one of your current patients and whose name is listed on the EDIS tracker. The patient has a near respiratory arrest and needs to be intubated.”

The report adds that although such errors happen with paper-based systems, “an alarming number of clinicians are anecdotally reporting a substantial increase in the incidence of wrong order-wrong patient errors while using computerized physician order entry components of information systems.”

It adds that “there are few consistent data on how commonly these errors occur, and few studies are actually focused on collecting evidence of these errors.”

4. Alert fatigue

The volume of frequent alerts and warnings “can dull the senses, leading to a failure to react to a truly important warning,” the report says. Unfortunately, the panel says, “the effect of alert fatigue on clinical decision support and computerized physician order entry has largely focused on patient care outside the ED” though it happens all too often inside the ED as well.

” ‘Warning! The patient has a documented allergy to penicillin. You must enter a reason why you wish to proceed with your order of cefepime.’

“You sigh, recalling the very low cross-reactivity between cefepime and penicillin. When you attempt to order vancomycin: ‘Warning! The patient has an adverse reaction to vancomycin. You must enter a reason why you wish to proceed with your order of vancomycin.’

” ‘What’s that?’ you think to yourself. ‘Didn’t we just do this?’ You click to get past the pop-up and order the antibiotic anyway. An hour later, a nurse has turned off the vancomycin infusion, asked you to order diphenhydramine, and is filing an incident report about a preventable adverse medication reaction.”

Vendor Recommendations

The report lists seven recommendations, some of which are directed at emergency department information system vendors. They are:

1. Each ED should have a clinician champion to lead a performance improvement group.

2. Such a group should be multidisciplinary, and meet regularly to communicate with ED and hospital leadership.

3. There should be a review process to monitor patient safety issues involving ED information systems, and providers and others should be encouraged to submit safety concerns for review.

4. Providers, vendors, and hospital administrators should address those concerns in a timely manner, with “full transparency, specifically with openness, communication, and accountability.”

5. Lessons learned should be measured and shared publicly, including with other EDs using the same information systems.

6. Vendors should learn from patient safety improvements and ensure timely distribution of necessary changes to all installation sites.

7. “Hold harmless” or “learned intermediary” clauses should be removed from vendor software contracts.