PrintUnintended consequences are not limited to the initial implementation phase. They can occur at any time before, during, and even long after EHR implementation. Continuously monitoring the functionality and use of the EHR will help you anticipate and avoid adverse unintended consequences.
Unintended consequences result from complex interactions between technology and the surrounding work environment. Even if your EHR implementation was well planned and executed, some unintended consequences may emerge after the EHR is being used on a day-to-day basis. The following list of recommendations for improving EHR safety should help you avoid a range of adverse unintended consequences that may occur during day-to-day EHRuse.
- Actively involve clinicians and staff in the reassessment and ongoing quality improvement of technology solutions.
- Continuously monitor for problems and address any issues as quickly as possible, particularly problems obscured by workarounds or incomplete error reporting.
- Use interdisciplinary brainstorming methods for improving system quality and giving feedback to vendors.
- Carefully review skipped or rejected alerts.
- Require departmental or pharmacy review and sign off on orders that are created outside the usual parameters.
- Provide an environment that protects staff involved in data entry from undue distractions when using the technology.
- Continually reassess and enhance safety effectiveness and error-detection capability, including the use of error tracking tools and the evaluation of near-miss events.
- Use manual or automated surveillance techniques to continually monitor and report errors and near misses or close calls caused by technology.
- Pursue system errors and multiple causations through root cause analysis (finding the real cause of the problem and dealing with it rather than simply continuing to deal with the symptoms) or other forms of failure-mode analysis.
Source:The Joint Commission. Sentinel Event Alert: Safely implementing health information and converging technologies. Dec. 2008.
A systematic approach for identifying risks that are introduced by the EHR will help you anticipate and avoid unintended consequences. Useful tools have been developed that can help you systematically evaluate the risks associated with the use of your EHR.
Failure Modes and Effects Analysis: (FMEA) is a systematic method used to proactively evaluate health care processes and to identify and assess potential vulnerabilities. The Department of Veterans Affairs provides a tutorial on how to apply the FMEA methodology in health care settings.
CPOE + FMEA = Fewer Medication Errors: Pediatric chemotherapy is very complex, involves many risks, and leaves little margin for error. A Pediatric Oncology Department conducted a failure modes and effects analysis (FMEA) of their process for pediatric chemotherapy
EHR Usage Metrics
Metrics can help you track the functionality and usage of your EHR. For example, the following list of metrics was developed to monitor the use of CPOE systems. These measures are useful as examples of what can be developed to assess and improve the usefulness of an EHR. The reporting and audit capabilities of EHRs will vary, but it may be useful to evaluate potential vendors on whether their products will allow you to track these (or other similar) usage metrics.
- Percent system uptime: calculated as the number of minutes the EHR was fully functional in a given month divided by the total number of minutes. Planned as well as unplanned downtimes should be deducted from the numerator. Downtimes should include any time period when systems that affect clinical use were not functioning properly.
- Mean response time: measured to the tenth of a second and calculated for any number of routine tasks (for example, accessing a patient's medication list).
- Percent of orders entered: the percent of all orders entered electronically.
- Percent order sets used: the percent of order sets (prefilled ordering templates or electronic protocols derived from evidence-based best practice guidelines) that have been used in the last 12 months; a similar measure could be calculated for other templates.
- Percent alerts that fire: the percent of alerts that have fired in the last week, month, and quarter (a measure of the utility and sensitivity of the alerts).
- Percent alerts overridden: the percent of alerts that are overridden by clinicians.
- System interface efficiency: measure of how well the EHR communicates with ancillary systems (e.g., pharmacy, lab, PACS, etc.). This could be calculated as the number of successful transmissions between systems divided by the total number of transmissions attempted.
- "Miscellaneous" orders: the number of miscellaneous or free text orders should be monitored. (Free text entry disables the capacity to provide decision support).
Source: Sittig DF, Campbell E, Guappone K, et al. Recommendations for Monitoring and Evaluation of In-Patient Computer-based Provider Order Entry Systems: Results of a Delphi Survey. AMIA Annu Symp Proc 2007; 2007: 671-675.
In order to qualify for Federal "meaningful use" incentives, health care providers must monitor and report the use of the EHR in their organization. The toolbox below provides links to the Federal meaningful use criteria.
Meaningful Use: CMS provides information about the Federal EHR incentive program
Soliciting User Feedback
Make it easy for users to provide feedback or report errors and for the organization to respond to them. Module III describes strategies for error reporting. Module IV focuses on the remediation of EHR-related errors.
In addition to these strategies, regular surveys of clinicians can give you a sense of how the system is being used and what functions are the most or least useful. These surveys may also alert you to patterns of use that may be suboptimal or even dangerous.
Example User Survey: The New York Department of Health and Mental Hygiene and Columbia University developed a survey that can be used in whole or in part to assess how the EHR is being used in your organization.
Auditing the Use of Copy and Paste
Copying clinical documentation can be a time-saver for busy clinicians; however it also can pose a risk to the integrity and utility of medical records and can even affect patient safety. Organizations that allow use of the copy and paste function in their EHR systems may need to audit its use in order to maintain compliance with State and Federal requirements.
Copy and Paste Toolkit: The American Health Information Management Association has developed a toolkit that includes resources to help health care providers develop policies related to the use of copy and paste, training materials to promote the appropriate use of copy and paste, and methods to monitor the use of copy and paste within their EHR.
Dealing with the Persistence of Paper after EHR implementation
"Going paperless" in health care is a lengthy process, and it is likely that the use of paper records and forms will persist even after you implement an EHR. Paper does offer some features such as flexibility and tailorability that digital mediums presently do not. However, the persistence of paper records and paper-based information tools poses a problem when these tools are used as "shadow" medical records or are used to circumvent processes or checks that are enforced in the electronic systems. Best practices for using paper in an EHR environment are not available; however some research has described the reasons why paper persists in health care work environments and how paper might be used more safely and effectively.
Paper Persistence after EHR Implementation: The Computerized Patient Record System (CPRS) is implemented throughout Veterans Affairs Medical system. A recent study indicated that clinicians in the VA system consistently use paper to work around the limitations of CPRS. Some examples of the workarounds they identified include:
No matter which system or vendor you choose, you will regularly be required to update your EHR software. When software updates do occur, you should be aware that such updates, by design, change the functionality of your EHR and therefore may also lead to unanticipated and undesirable changes in the way your EHR functions or is being used.
User Frustration with Frequent EHR Updates: A behavioral health and substance abuse facility implemented a new EHR. Many staff members were frustrated by the seemingly constant changes and updates to the system. One staff member said that she struggled to keep up with the "continual upgrades and modifications" and that she feels like the "target is always changing." Implementation of the EHR led to a decrease in staff morale, and a number of staff members left as a result.
Despite Testing, Unintended Consequences Can Still Occur:After a year of testing at multiple sites, a large integrated health system was ready to roll out a system-wide software update for their EHR. Not long after the update, users reported that physician orders to stop medications had gone missing. The "missing" stop orders had caused some patients to receive intravenous medications longer than necessary
In the next module we offer tools and information to better understand and identify unintended consequences. Much of Module III is based on a model of interactive socio-technical analysis (ISTA) developed specifically to understand unintended consequences of EHRs.
