Top problems with EHRs and emerging risks jeopardize care quality

Health information technology (IT) and electronic health records (EHRs) can improve safety, helping to identify errors and delays in care before patients are harmed. But poor software interface design can stymie health IT’s promise, and even create problems and hazards.

“Most Americans will get a wrong diagnosis or a delayed diagnosis at least once in their lifetimes,” Hardeep Singh, MD, MPH, of the Houston VA Center for Innovation in Quality, Effectiveness & Safety, and the Baylor College of Medicine in Houston, Texas. Singh is also director of the VA Center of Inquiry to Improve Outpatient Safety through Effective Electronic Communication.

Singh was presenting at the “Special Symposium on Quality: Quality of Care in the Era of Health Information Technology,” at the American Society of Hematology (ASH) Annual Meeting in San Diego on December 3.

Health IT regulations were meant to hasten improvements in patient safety and quality of care by facilitating communication between healthcare providers, labs, pharmacies, and patients themselves.

But expectations for health IT have at times outpaced capabilities.

Technology ‘hype cycle’

There exists a “technology hype cycle,” Singh said. A new technology triggers excitement and soon, “a peak of inflated expectations.” A “trough of disillusionment” ensues, followed by a slower and less-excited “slope of enlightenment” as people learn about the real promise of the technology. As it becomes effectively deployed or implemented, a “plateau of productivity” is eventually achieved: The technology becomes accepted and routine. It is no longer novel.

For many, Health IT has reached the “disillusionment” stage, he said. That’s because initial implementation and use are “inherently prone to failure” and require overhauls of underlying architectures and processes.

“We never prepared for the unintended consequences of health IT,” he said, noting headlines about software glitches that resulted in the generation of prescriptions for wrong drugs, and other problems, in recent years.

Root of the problem

Often, a big part of the problem is the software interface with users, he said. Onscreen clutter can overwhelm busy users. Usability is key, he said. Better user interfaces improve the signal-to-noise ratio.

“Comments” windows or free-text fields can afford clinicians flexibility, allowing them a place to make clarifications not anticipated by software designers, for example. But they can also be an opportunity for ambiguity, inconsistency, and confusion.

And that, in turn can cause quality-of-care and even safety concerns.

“As doctors, we like to give instructions to patients and pharmacists,” Singh said. “But if a note says, ‘Take 5 mg a day on Saturday and Sunday,’ does that mean take only 5 mg, or an extra 5 mg? What does it mean?”

A Veterans Administration health IT system suffered from exactly this kind of problem for a decade before it was remedied, he noted. “We never prepared for these problems.” Physician’s instructional notes were sent to patients without software safeguards to spot or flag potential ambiguities.

Studies show that many online patient-records portals-or the way they are populated or used by clinics and hospitals-is frequently a source of confusion and frustration for patients. For example, lab results may not be organized logically, such as by date.

“About 7% of clinically-significant abnormal test results are never reported to patients,” Singh said. “That’s a problem of communication. And health IT should be able to solve problems of communication. But [it’s] not!”

Next: Tech not the only problem

Technology not the only problem

That is, in part, because these problems stem not only software-design problems. Health IT problems are “socio-cultural” as well as technological, he explained. Organizational policies, procedures and culture play a role. So do work flow, communication, personnel, and monitoring.

“That’s why it’s so hard-that’s why we are having so much trouble using the EHRs,” he said. “You really need each of these dimensions to be addressed.”                                                                                              

Problems can also stem from how clinicians use EHRs.

EHRs and lab-EHR interfaces “must be safe” and must be used safely, he said. “If you copy and paste, remember-that’s you doing that, not the EHR. And if you’re blowing off the system’s alerts, that’s a user problem.”

Software designers’ instincts, in the face of such problems, is often to further constrain clinicians’ possible inputs with on-screen scroll-down lists or checkbox options. But this creates its own problems, making menus cumbersome and robbing clinicians of time with patients-or encouraging clinicians to skip steps and ignore prompts. “Too many clicks” can slow work flow.

Physicians receive more than 60 EHR alerts each day, Singh noted.

“How many of you override alerts on a routine basis,” he asked the audience, pausing momentarily before declaring to laughter, “Most of you!”

Emerging risks

Singh’s research has identified “emerging risks, like failures to elicit or act upon key history or exam findings and red flags,” he reported. “Do EHRs constrain how we think?”

Some problems are relatively basic and can be addressed by prompts-if those prompts are not ignored. Physicians frequently fail to read nurses’ notes, for example. That can lead to problems whether notes are on paper or in a patient’s EHR.

Singh reported that another frequent problem is that when information like lab results is automatically reported to more than one clinician, each recipient will assume the other will act on that information.

“We need better protocols and a better support culture,” Singh said. “Does your institution have a policy that says explicitly who is responsible for follow up on [EHR-reported] findings?”

Clinics and hospitals also need to adopt evaluation and measurement practices that allow timely detection of problems and their use to learn-and to improve the quality of patient care, he said.

“We need better decision-support in the EHRs,” Singh said. “Software, content, usability-we’re not there yet.”