How badly designed electronic health records can put patients in danger

The clunky interfaces of electronic health records aren’t just a pain for clinicians to work with — they can also occasionally endanger patients, new research says.

A team of researchers at MedStar, a not-for-profit health care system headquartered in Maryland, collected nearly 2 million reports of safety hazards from clinics in Pennsylvania and the mid-Atlantic region. Of those, 557 explicitly said that a problem with the electronic health records put a patient in danger, according to the article published yesterday in the Journal of the American Medical Association.

Electronic health records, or EHRs, are digitized medical charts that include key information about a patient’s history, medications, allergies, and previous doctor’s visits. They’re supposed to put together the overall picture of a patient’s health, streamlining care, according to the Centers for Medicare & Medicaid Services. While the system has reduced certain kinds of medication errors compared to paper medical charts, clinicians also report that trying to operate the cumbersome software is frustrating, says Raj Ratwani scientific director at MedStar’s National Center for Human Factors in Healthcare and senior author on the study.

“It’s clear that the introduction of electronic health records is not making things worse over time,” says David Blumenthal, president of the Commonwealth Fund philanthropy and former national coordinator for health information technology under President Barack Obama. “But I think better-designed records could make things better still,” says Blumenthal, who was not involved in the study.

Ratwani’s team set out to find out how exactly EHRs could improve by figuring out how they’ve failed. They analyzed safety hazards self-reported by doctors and nurses ranging from errors that required a close watch on their patients (84 percent), to ones that threatened patients’ lives (less than 1 percent). Some of the mistakes had to do with the EHR’s interface, which made it difficult for clinicians to enter data accurately, Ratwani says.

In one case, the EHR allowed a clinician to record a child’s weight in kilograms rather than pounds, which could have led to dangerous overdoses of medications that are measured out by weight. In other cases, the EHR failed to alert doctors and nurses to life-threatening conditions like allergies to drugs like penicillin; theoretically, EHRs should alert clinicians to the allergy when they’re trying to prescribe the drug. The problem is that with badly designed EHRs, Ratwani says, “the alert feature may not work or the alert may not be clear, and it doesn’t actually convey the core message to the provider in a way that’s usable.”

Overall, about 0.03 percent of the errors could be linked to EHRs, the study says. Those errors were self-reported, so they might not represent the full range of mistakes, Blumenthal says. While this study shows that electronic health records are associated with medical errors, Blumenthal says “they constituted a very small number of the reports of errors, which is reassuring. And there were relatively few reports of very serious issues.”

Still, that small percentage is almost certainly an underestimate, Ratwani says: the bulk of the patient safety reports were from 571 clinics in the state of Pennsylvania. So more examples might be found if the search is expanded nationwide, he says. Plus, the team specifically looked for patient safety reports that explicitly named one of the top five electronic health record vendors or one of their products. “But it’s not natural for people to report that way,” Ratwani says. “They’re focused on what happened to the patient and details about the patient. They’re not focused on naming the product.”

So what’s the solution? One that’s already in place is to have well-trained caregivers who can spot errors in the EHRs, Ratwani says. But there are still mistakes that fall through the cracks, which patients could catch if they had easy access to their health care information. That’s something Apple is working on improving. In January, the tech company rolled out an update with the iOS 11.3 beta that makes electronic health records for more than a dozen medical institutions available in the iPhone Health app. “An engaged patient is a safe patient,” Ratwani says.

But that, too, is not a complete or long-term solution. Having your own medical records on your device won’t really change how clinicians interact with EHRs in the hospital, for example, where you might not be physically able to whip out your phone and check their work. The long-term solution really is that we have to focus on the usability and safety of the EHR itself, and not rely on patients catching these issues,” Ratwani says.

That’s why studies like this one are useful, Blumenthal says. It points out ways in which EHRs still need to improve. “Improvement is always necessary, and it’s quite possible in the electronic world,” he says. “Much easier than in the paper world.”

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