The safety of an EHR is a necessity in the era of automation

Since the passing of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, the adoption of electronic health records has accelerated across the US healthcare system from large academic medical centers to single physician offices, growing from less than 10% in 2008 to 96% in 2015. This huge increase in the use of the electronic health records (EHR) in providing direct care to patients and interacting with the whole system raised many questions about safety, reliability, and ease of use of such system.

I am an Emergency Physician by training and I use the EHR to practice medicine, provide care to my patients, interact with diagnostics, and communicate with my colleagues. I have been part of the optimization EHR systems for many years, and three years ago, when we decided to replace our existing EHR with a new one to cope with the rapid expansion of our healthcare system, I knew that this would be a challenging and interesting journey. For professionals and institutions who face this challenge on daily basis, I wanted share some of the knowledge and resources that you can use my dear reader to assess and improve the safety of your EHR.

The Sociotechnical System for designing systems

In looking for ways to make health IT-assisted care safer, it is important to recognize that the products are not used in isolation. Rather, they are part of a larger sociotechnical system that also includes people—such as clinicians or patients— organizations, processes, and the external environment. Safety exists from the interactions of these factors. Comprehensive safety analyses, therefore, should not look for a single “root cause” of problems but should consider the system as a whole in looking for ways to reduce the likelihood that any given patient will experience an adverse health event.

The figure was adapted from: Harrington et al. (2010), Sittig and Singh (2010), and Walker et al. (2008)

Other issues we should consider in healthcare systems:

• Healthcare organizations are complex adaptive systems (CAS) composed of multiple diverse elements that are capable of adaptation and thus grow over time to exhibit highly complex behavior. For more, read Making Systems Safer.
• Healthcare professionals do not perform tasks, like processing a cheque in financial institutions, what they do is make choices that are modified through an expanding knowledge base and contact with the system. So systems should not automate a static process but rather should focus on the dynamic, ever-changing environment.
• Healthcare professionals are not resistant to technology; on the contrary, the IT innovation in healthcare is growing exponentially. They are however resistant to bad technology that makes caring for patients harder and converts them into data entry professionals rather than clinicians.

Tools to Measure EHR Safety

With this explosion in use of EHRs, safety measuring surveys and tools were created to assist users and organizations in assessing the safety of their systems.

• The SAFER Guides: Developed by The Office of the National Coordinator for HIT (ONC) (under the U.S. Department of Health and Human Services) to enable healthcare organizations to address EHR safety in a variety of areas, and identify recommended practices to optimize the safety and safe use of EHRs. The guides consist of nine guides organized into Foundation Guides, Infrastructure Guides, and Clinical Process Guides.
• The Leapfrog Group CPOE Survey: A part of the Leapfrog Group hospital survey that addresses the Computerized Physicians Order Entry Systems (CPOE). Many institutions in US use it.

The SAFER Guides, COPE and DS Checklist filled by MNGHA.

Measuring and Reporting EHR Adverse Events

We report many adverse events through safety reporting systems, but only a few organizations track and report technical issues in their EHR, analyzing them as they do with medication errors, for example. Sittig et al have proposed many measures that could be applied to many organizations and even nationally to inform policy and improvement.

Source: Sittig DF, et al. J Am Med Inform Assoc 2015;22:472–478

Organizational Experience

Our organization rolled out a full new EHR system with advanced functionalities, replacing our old EHR in order to cope with the expansion in our services. The project took place during 2015 and 2016, involving two Academic Medical Cities with highly specialized institutions, three secondary care hospitals and tens of primary care centers. In order to ensure the safety of patients during the roll out, we implemented some strategies like:

• Training of all staff, the super-users, through simulation: That was done both in person and through virtual training, establishing a training station in the institution that works in a shift system to match staff times and clinical responsibilities, and unit-based simulation utilizing patient scenarios.
• Go live during the weekend: To take advantage to lower patient flow, limited staff engagement in other duties, and the closed outpatient clinics.  
• Leadership and Command Center: Leadership plays a crucial role in the success of such a transformational project. We established a command center that meets twice a day for briefings and debriefings that are attended attended by top leadership, clinical units leaders, and the implementation teams. The main function was to communicate issues from front-line staff, prioritize and address those issues in real-time, and give feedback to staff.

What has been your experience with EHR implementation or improvement in your insinuation? Are EHR systems designed to improve safety? Are they properly designed to match the work flow of healthcare professionals or do they reduce efficiency? ... Please leave a comment below.