Issues Encountered

To reduce the risk of medication overdoses, a nursing home implemented "intentional blocks" in the order entry system. These blocks would not allow providers (most often nurses) to order medication doses that exceeded typical thresholds. To circumvent the blocks, nurses simply ordered multiple doses of the same medication in order to obtain the full dose that they desired.

A study of the use of an EHR in five nursing homes identified several other instances in which clinicians felt that they needed to work around the system in order to accomplish their work tasks. Examples of other potentially hazardous workarounds included:

1. A two-stage medication administration documentation system was designed to encourage staff to document preparation of the medication and then to return to document administration after it had taken place. The system was viewed as overly cumbersome, and most staff documented both preparation and administration in a single session — before actually administering the medications.
2. The EHR was designed to print out an individual sheet of paper for each medication order. Medication orders were then to be faxed to the pharmacy. The nursing home staff found that it was too time consuming to send multi-page faxes. Staff used two different approaches to work around this issue: 1) some staff would forgo faxing altogether and simply call the orders into the pharmacy; 2) some staff preferred to transcribe all of the medication orders onto a single sheet of paper and then send a one-page fax.
3. Many of the staff found that the EHR's response time was too slow. The slow response time, combined with the need to click through several different screens to access comprehensive patient information, led staff to employ other information-retrieval methods. For example, it was not uncommon for staff members to rely on handwritten notes or consult with other staff members to obtain the information that they needed, instead of looking it up in the EHR.

Finding a Solution

How to best deal with EHR workarounds is still an open problem. Workarounds may not necessarily be bad, and they may be preferable to expensive system modifications and upgrades. However, workarounds can be dangerous, and they should be monitored and, where possible, standardized. If you choose to incorporate a workaround into your workflows, you should carefully analyze the process to ensure that it does not put patients at risk. Systematic methods to study your processes are discussed in Module II.