The money “spent in adoption should have been spent in innovation and development and research to show what works and what doesn’t well before you started pushing adoption,” Dr. Rogers says. “But at this stage, we can’t go backward … the plan is in flight, and we have to try to repair it in the air at this point.”
To that end, The Joint Commission in March 2015 issued a Sentinel Event Alert to highlight that the safest use of HIT still needs structural improvement. The Joint Commission analyzed 120 sentinel events (which it defines as unexpected occurrences involving death or serious physical or psychological injury or the risk thereof) that were HIT-related between Jan. 1, 2010, and June 30, 2013. Eighty percent were issues with human-computer interface, workflow and communication, or design or data issues tied to clinical content or decision support.
“As health IT adoption spreads and becomes a critical component of organizational infrastructure, the potential for health IT-related harm will likely increase unless risk-reducing measures are put into place,” the alert stated.
To that end, The Joint Commission recommends:
- Focusing on creating and maintaining a safety culture;
- Developing a proactive approach to process improvement that includes assessing patient safety risk; and
- Enlisting physicians and administrators from multiple disciplines to oversee HIT planning, implementation, and evaluation.
Dr. Edwards
Terry Edwards, chief executive officer of PerfectServe, a Knoxville, Tenn., firm that works on healthcare communications systems, says that a survey his firm conducted in 2015 found that, among clinicians needing to communicate with an in-house colleague about “complex or in-depth information,” an EHR is used 12% of the time. Just 8% of hospitalists surveyed used it. The rest used workarounds, face-to-face conversations, and myriad customized solutions to communicate.
“Workarounds happen all the time in healthcare because many of the tools and technologies impede rather than enhance a clinician’s efficiency,” Edwards says in an email to The Hospitalist. “It’s pretty clear that many physicians are frustrated by EHR technology.”
Backwards Revolution
The natural question around unintended consequences: Why didn’t physicians or others see them coming as EHRs and HIT were burgeoning the past decade? Dr. Rogers says that hospitalists and physicians weren’t involved enough on the front-end design of EHRs.
So instead of systems that have been built to be intuitive to the real-time workflow of hospitalists, nurse practitioners, and physician assistants, the systems are built more for back-office administrative functions, he adds.
Dr. Rogers
“When we have programmers and non-clinical people trying to build products for us, they’re dictating our workflow,” Dr. Rogers says. “In many cases, they don’t understand our workflow, and in many more cases, our workflow differs from the last person or the last hospital they worked at.
“This is where we get into issues around usability.”
Take the overdose patient at UCSF. One wrong number typed into a single field led to the oversize dosage. Safety redundancies built in the system flagged the excessive dosage each time, but at each point, a human decided to keep the dosage at the incorrect size because, essentially, everyone trusted the EHR.
All of those red flags come with their own unintended consequence: alert fatigue.
“When people really get fatigued with all of these alerts, they start to ignore them,” says hospitalist Cheng-Kai Kao, MD, medical director of informatics at the University of Chicago Medicine. “So now here comes the question: How do we properly set the limit or threshold?”
In the airline industry, alerts are often tiered to give pilots an immediate sense of their importance. But Dr. Kao says the typical EHR interface is not that advanced, an often frustrating trait to younger physicians accustomed to user-friendly iPhones and web applications. The same frustration often is found with the litany of medical devices hospitalists interact with each day.