Playing It SAFER

EHR Guides Help Frontline Physicians

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Practice Management Feature — June 2014

Tex Med. 2014;110(6):35-38.

By Kara Nuzback

Databases crash; backups fail. Sometimes, the very tools designed to help a practice operate smoothly from day to day can cause the biggest disruption themselves. 

Are you and your staff doing everything you can to make sure your electronic health record (EHR) system doesn't botch prescription information or confuse one patient with another? If you're not sure, a new toolkit can help you find out.

The Office of the National Coordinator for Health Information Technology (ONC) released a free toolkit in January to help health care organizations identify and mitigate patient safety risks associated with EHRs. The Safety Assurance Factors for EHR Resilience (SAFER) guides are available online.

Houston internist Hardeep Singh, MD, helped develop the guides, which he says can improve the quality and safety of EHRs in a real-world practice setting. 

Dr. Singh is a patient safety researcher at the Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey Veterans Affairs Medical Center and an associate professor at Baylor College of Medicine. 

For the past five years, he has researched EHR-related patient safety risks, one of which involves clinician entry of inconsistent prescription information in the EHR system. If a physician wants to prescribe warfarin, for example, the EHR's order entry interface likely includes a drop-down menu to select the drug's strength, commonly 5 or 10 milligrams, Dr. Singh says. 

While physicians select the dosage from an electronic list of selections, they also may write free-text notes to clarify the dose, which can contradict the electronic selection. 

"This contradictory order introduces ambiguity," he said.

An ambiguous prescription leaves pharmacists and patients confused and patients at risk. 

Even without ambiguity, a computer glitch or a typographical error could change a prescription from 3.0 milligrams to 30, or an EHR alert system could become an annoyance to a physician who begins to ignore the alerts and overlooks an important drug interaction notification.

Because EHR systems are new and continually evolving, Dr. Singh says, "introducing technology into health care is complex," and health care professionals are just now beginning to understand new types of unintended consequences resulting from the use of EHRs. 

ONC sponsored the SAFER project to develop practical tools for practicing clinicians and hospitals. The tools allow physicians to close loopholes in the practice's EHR system that could put patients at risk.

"SAFER guides help us anticipate and deal with consequences," Dr. Singh said. "The goal is to develop guidelines for the front lines." 

A Team Approach

Each SAFER guide includes a recommended practice checklist that you can download and use to assess a practice's EHR system safety components. For example, a checklist item might say, "The status of orders can be tracked in the system." The user can rate the item as fully, partially, or not implemented, depending on the EHR's capability. 

If the practice has not fully implemented orders tracking in the system, or if the user is unsure, an accompanying Recommended Practice worksheet provides guidance on the importance of tracking orders and suggestions for resources to provide more information about it. 

Clinicians can save the Recommended Practice worksheet for further review and forward it to others. (See "Practice Makes Perfect.")

The authors of the SAFER guides — Dr. Singh; Dean Sittig, PhD; and Joan Ash, PhD — recommend setting up a multidisciplinary team for each of the nine guides to evaluate which of the recommended practices are already being done and which practices need to be implemented to strengthen patient safety. 

For example, Dr. Singh says, the Test Results Reporting guide team could consist of one or more clinicians, information technology staff, lab personnel, practice leaders or administrators, and an EHR vendor.

Dr. Singh says it is important to have meaningful conversations on safety with all the stakeholders involved, including EHR vendors. 

After completing the checklist in each guide, the multidisciplinary team can use the Team Worksheet included in each guide to document its assessment. The Team Worksheet allows the group to assign a team leader; identify team members and their roles; record the self-assessment completion date; and add notes about considerations, conclu¬sions, pending software updates, and more.

Small practices should start with the High Priority Practices guide, which poses questions about computer downtime, backup availability, and procedures to ensure correct patient identification. Practices can then see which EHR safety hazards need to be addressed immediately, Dr. Singh says. 

After users review the High Priority Practices guide, they can complete the remaining guides in order of where patient safety risks are likely to occur in the system, he says.

The Grand Challenge

Dallas pediatrician Joseph Schneider, MD, chair of TMA's Council on Practice Management Services, says physicians must select an EHR system carefully and use the SAFER guides to make sure they implement the system correctly. 

Dr. Schneider hopes the guides become a popular tool among physicians, but he says it's too early to tell how effective they will be. 

"They won't take care of everything, but if they can help you avoid one or two major problems, then the time people spend looking at them is probably worth their weight in gold," he said. "In my years of using EHRs, I've selected the wrong form of medicine more than once because of poor EHR design." 

Dr. Schneider says typographical errors are easy to make in EHR systems and can be hard to correct. For example, he says, a staff member might intend to enter a premature infant's weight as 4.1 pounds but forget the decimal and enter 41 pounds. The bad data might not be noticeable until weeks or months later, perhaps when the growth chart shows a spike where one should not exist, he says. By then, it might be too late to change the data.

"In the paper world, you would never write '41 pounds' for a two-month-old," he said. "Not all systems are clever enough to alert you that you can't have a 41-pound two-month-old."

But most EHR systems are not capable of summarizing patient information or suggesting treatments to better aid physicians, says Dr. Sittig, a professor at The University of Texas School of Biomedical Informatics.

"That's what I call a grand challenge. That's what computers are supposed to be able to do," he said.

According to "Electronic Health Records and National Patient-Safety Goals," a 2012 New England Journal of Medicine article by Drs. Sittig and Singh, the number of certified EHR vendors in the United States increased from 60 in 2008 to more than 1,000 in 2012. The article says many vendors focus on using EHR technology to achieve meaningful use requirements instead of focusing on patient safety.

Dr. Sittig says EHRs are a relatively new form of technology. Ultimately, he hopes EHRs will be able to recommend treatments for individual patients, much like Amazon can suggest books based on what the customer has already read.

"The first thing we have to do is get people to use the computer system," he said.

Most physicians are not computer experts, and many doctors who have a 20-year history of using a paper system are likely finding it difficult to transition to EHRs, he says.

"In the old days, the doctor would scribble on a piece of paper or call in the nurse," Dr. Sittig said. "The computer is now requiring people to do more work than before, and it's a new kind of work."

Even with minimal computer experience, physicians know it should not be as hard as it often is to use EHRs, Dr. Sittig says. The SAFER guides empower physicians to expect more from their EHR system, including the fast processing of information.

"It should take less than a second to get lab results on the screen," he said.

By allowing physicians to expect more, the guides can give professionals the confidence to call their IT staff or EHR vendor and demand the systems be fixed or upgraded when they encounter flaws, Dr. Sittig says, adding the more knowledgeable doctors are about EHRs, the less they will stand for glitches.

But that doesn't mean doctors can pass all the responsibility. Basic typing skills and time commitment are pivotal to ensuring the systems operate correctly.

"The guides require more work, and they're going to require physicians to invest more money, and they require EHR vendors to offer some new features," he said.

Dr. Sittig believes that if health professionals implement and regularly review the SAFER guides for the next five years, superior EHR technology will hit the market. 

"Eventually, better systems are really going to improve patient care," he said.

Dr. Singh says he foresees three phases in the evolution of EHRs: Develop safe technology, learn how to use it safely, and monitor and measure its performance.

"It's a starting point," he said. "We think this process of evolution is going to be long but fruitful and will improve patient care and health outcomes."

Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.


Practice Makes Perfect

Health professionals in any practice setting can use the Safety Assurance Factors for EHR Resilience (SAFER) guides to assess the organization's electronic health record (EHR)-related patient safety risks based on a list of recommended practices. Health care professionals do not need to review the guides and implement the best practices in any specific order, says Hardeep Singh, MD. Each of the nine SAFER guides analyzes a specific EHR system component: 

  1. The High Priority Practices guide provides an overview of the eight other guides and allows clinicians to check whether their organization is adhering to basic patient safety practices in its EHR system, such as permitting clinicians to override computer-generated clinical interventions and ensuring they are using the EHR to order medications and tests. It enables practices to decide which of the guides they need to complete immediately to ensure patient safety. 
  2. The Organizational Responsibilities guide addresses possible errors in the EHR system that could put patients at risk. It includes recommended practices, such as regular EHR training and support to help ensure safe EHR use. 
  3. The Contingency Planning guide helps practices prepare for times when computer systems are down. Recommendations include providing staff training on recovery procedures and making hard copies of important documents.
  4. The System Configuration guide encourages users to test the EHR system to ensure proper hardware and software setup. For example, practices can house the EHR in a physically secure site.
  5. The System Interfaces guide helps the practice confirm all EHR-related software systems work together. It recommends ensuring all clinical vocabulary is the same in each system and establishing a system of information exchange that is clear so users know when the system cannot transmit or receive messages or crucial information. 
  6. The Patient Identification guide ensures the system can identify the correct patient so prescriptions and test results don't get mixed up. Recommendations include making sure the EHR system warns users when they attempt to create a new record for a patient with the same first and last name as another patient. 
  7. The Computerized Provider Order Entry (CPOE) with Decision Support guide helps practices safeguard electronic orders. Recommended practices include training and testing clinicians on CPOE operations before giving them credentials to log in to the EHR system. 
  8. The Test Results Reporting and Follow-up guide helps practices safely manage and share diagnostic test results. It includes recommended practices such as flagging abnormal test results and putting mechanisms in place to forward results from one clinician to another.
  9. The Clinician Communication guide focuses on the safe use of EHRs among clinicians. Recommended practices include keeping copies of clinician-to-clinician communications in the EHR system and putting mechanisms in place to monitor the timeliness of acknowledgment and response to messages. 

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