Targeting EHR Workarounds
Many in the health IT sector and the health professional community view electronic health records as both a blessing and a curse. EHRs have significantly improved documentation and dissemination of patients' clinical information, streamlined certain tasks and improved safety in areas such as medication management. But EHRs also have made some aspects of health care providers' workload more time consuming than in the "paper" days and sometimes compromise patient safety.
EHRs' negative effect on workflow is a chief reason why clinical users are tempted to devise and use workarounds to simplify or expedite task completion.
Those workarounds, depending on the system and the user, might be harmless in some cases but potentially dangerous in others.
Dean Sittig -- professor of biomedical informatics and bioengineering at the University of Texas and a leading health care safety researcher -- said a "frequent offender" workaround is copying and pasting information from a past patient visit to a current one, or from one patient's record to another.
"This is a potentially super risky workaround that's very common," Sittig said.
The recently formed Partnership for Health IT Patient Safety -- a multi-stakeholder collaborative that was convened by the not-for-profit safety organization ECRI Institute -- recently published a special report on copy/paste prevalence and problems and is developing a best practices toolkit that will be available soon.
While some EHR copy-and-paste activity is both necessary and advisable, Sittig noted that the workaround can have disastrous consequences if it's done inappropriately. "Organizations really should have policies on this, on what's okay to do and what isn't," he said.
Risky Workarounds Common
In addition to copy-and-paste, there are numerous other EHR workarounds used in the hospital setting. Although there are scant data on their prevalence, some of the most common workarounds that health IT safety professionals have cited are:
- Opening up a second patient's chart on the same computer terminal to deal with an interruption, which can lead to entering an order on the wrong patient;
- Calling in or faxing pharmacy orders or prescriptions because it's faster than using the EHR, thereby potentially either duplicating an order or failing to have it appear in the EHR as it should;
- "Queueing up" medication orders for drugs that will be administered to the patient several times in a single shift or day, or individual doses to get to a desired dose that isn't an option in the EHR;
- Giving nurses or others hand-written physician notes or instructions to enter into the EHR, to avoid having to personally input data into the EHR;
- Overriding or blindly accepting all clinical decision support suggestions, some of which might have changed the course of care ; and
- Selecting the "all normal" option to complete an EHR review, which might result in oversight of non-updated or possibly erroneous data.
Patient ID scanning is another potentially high-risk workaround, according to both anecdotal reports and adverse events analyzed by patient safety organizations.
Lorraine Possanza -- a senior safety, risk and quality analyst and health IT patient safety liaison for the ECRI Institute -- cited another workaround that could compromise safety: instances of nurses scanning a printed sheet of patients' barcoded IDs rather than scanning the patient's wristband itself, as recommended, presumably to save time.
"We have also seen cases in which a patient's medication list is scanned into the EHR [as an image], rather than entered, which could result in alerts not being triggered," said Possanza, who was a podiatrist and health law attorney before she moved into the quality and safety field.
Possanza recommended that hospitals have their chief medical information officers and chief nursing information officers, or some equivalent team, conduct walk-arounds on the hospital floors periodically, as the activity often yields evidence of potentially risky EHR workarounds. She said, "If you walk the floors, you will hear people talking about issues they're having with EHRs, such as difficulty locating a particular field or screen," adding, "This helps [organizations] identify things that need to be fixed or changed."
Tejal Gandhi, a longtime health IT quality researcher who now leads the National Patient Safety Foundation, suspects that there might be other EHR workarounds that aren't even on officials' radars yet. "That's one of the key issues -- we don't have good data on these workarounds, so we're stuck with the anecdotal as we try to determine which workarounds to address as a priority," she said.
Design, Configuration Culprits
Some EHR users and health IT professionals cite EHR design or configuration issues, and well as health care organizational factors, as reasons for using workarounds. For example, system configuration that incorporates too many active alerts or alarms can lead to users, out of frustration, overriding them or declining to read the alert content.
In other cases, EHR systems either display too much information simultaneously or require navigating numerous click-throughs or drop-down menus to get to the desired field, which might prompt users to find a workaround. Gandhi said, "If a system is too laborious or cumbersome to use, clinicians might look for a more efficient way to do something."
However, Sittig noted that in some instances the workaround is prompted by a facility-infrastructure issue. Servers, terminals or networks might be significantly underpowered or overburdened, affecting response times. And sometimes there simply aren't enough workstations to go around, prompting users to "gang up" their activity by accessing several patients' charts in a single session.
Similarly, how individual organizations configure systems or develop their EHR-associated policies might inadvertently aid and abet workarounds.
Sarah Corley -- CMO at NextGen Healthcare and vice chair of the HIMSS Electronic Health Record Association -- urged organizations to examine these considerations to identify factors that prompt unsafe workarounds. "Configuration or policy decisions that require the physician [or nurse] to enter the bulk of data that [are] not clinically relevant can contribute to decreased productivity and prompt a search for improved efficiency," she said.
Corley added that organizational decisions to "configure drug alerts to be triggered by minor or poorly documented interactions, or setting up too many active alerts" for liability or other reasons are known to cause alert fatigue, which likely has been a factor in numerous adverse events safety organizations have analyzed.
She also pointed to the burden of regulatory requirements for documentation as a potential cause for clinician workarounds, and the increasing use of scribes to enter data in EHRs to offload physicians as a potentially significant safety risk where physicians fail to review or check the entries. To reduce such potential risk, Corley said, "There needs to be better clarification on the part of CMS and commercial payers as to what documentation is allowable by non-physicians."
Addressing EHR Workarounds
Many organizations are still trying to get their EHR systems appropriately implemented to meet their basic needs, so it's unlikely that they've got the resources to focus on workarounds to the extent that they should, Sittig said. In the interim, he urged organizations to take a global approach to identifying where EHR design or configuration issues might be leading to workarounds. He said, "Organizations should develop better measurement and monitoring tools to help them figure out when their EHR is working appropriately and when it is not."
Gandhi agreed, saying, "There really needs to be a mechanism for staff to tell you when something isn't working." She added that there needs to be assurance that if staff members report an issue that's prompting workarounds, someone will try to address it.
Gandhi said, "I think it's also important to ensure that your organization's safety and IT departments aren't siloed -- because your safety staff might have expertise that your IT personnel will find useful."
Further, Gandhi said organizations should not shortcut initial EHR training and should offer more longitudinal "continuing" training to users. Ideally, she added, organizations should also have their EHR "super users" periodically assess how EHRs are affecting workflow and identify solutions where issues might be leading to workarounds.
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