Health information technology and electronic health records continue to gain favor in healthcare. These systems are expected to bring improvements in patient safety, work processes and reduce rates of treatment and medication errors. To date, research is mixed on whether such improvements have occurred in the hospital setting. While studies find benefits, they also find HIT can have harmful effects on patient care and can increase inpatient mortality when it is inadequately implemented. Many studies, such as one recently published in American Journal of Managed Care look for common factors in successful implementation of hospital-based IT systems to avoid negative outcomes. While this type of research is helpful, experts at Anthelio Healthcare Solutions, a provider of healthcare IT solutions based in Dallas, believe that addressing the mechanisms behind poor health IT is a more effective method for eradicating the adverse effects. Here, Wendy Whittington, MD, MMM, CMO of Anthelio Healthcare Solutions, discusses ways poorly implemented HIT can cause adverse effects and how the industry could improve its HIT implementation and optimization for better patient outcomes.
1. Patient care delay. According to Dr. Whittington, much of a hospital or health system's patient information is decentralized on EHR systems, which can delay patient care. "As a hospital moves to an EHR, not all the data is incorporated and transferred at the same time. Half the information could be electronic and half could still be hard copies in a binder. This makes it difficult for physicians to find all the information they need in one search," says Dr. Whittington. This decentralization of information makes physicians hunt for the information they need, which delays diagnosis, treatment and recovery. For example, patient weight in one part of a record may not duplicate to other places, causing the physician to search for information needed for drug dosing. Each minute a physician searches for information could mean the difference between a positive and negative health outcome.
Solution
Dr. Whittington believes that there needs to be a bigger push for patient-centric EHRs to address problems with decentralized information. "The push for interoperability and health information exchange in CMS' Stage 2 meaningful use proposed rule is a good start, but more could be done," says Dr. Whittington.
2. Unnecessary tests and studies. Many EHR systems are not standardized which makes heath information exchange across providers more difficult and may lead to unnecessary tests and studies. For example, depending on the EHR system, a radiology report could represent as an image, a table or a graph. If a physician is used to seeing a radiology report as an image and a different provider's report presents as a table, the physician could misinterpret the report and order an unnecessary test. "If a physician works in hospital A and needs to order a test for a patient, that physician should be able to look at patient's record and know if hospital B did that test also. If that study was done, a second test is a waste of time, energy and resources," says Dr. Whittington. When tests are unnecessarily duplicated, it lengthens an individual's treatment and raises costs.
Solution
Dr. Whittington recommends a slightly radical solution — standardizing EHRs similar to how the banking and financial industry standardized bank routing numbers. "My view is that we need an affordable, one size fits all system. The more uniformity we have in our HIT the better. For instance, every bank has a routing number and they are all similar. There is no differentiation among routing numbers. That is the type of standardization the healthcare industry needs," says Dr. Whittington.
3. Disregarding vital information. Physicians and clinicians often develop alarm fatigue when using EHRs, and ignoring alarms and potentially overlooking vital information could lead to negative patient outcomes. Many EHRs have alarms for drug allergies, patient history and medication combinations. However, when physicians and clinicians receive alerts and distracting notifications, they may override them. This alarm fatigue could cause them to miss an important notification because many unimportant ones flashed first. "On a paper chart, there may have been red stickers alerting physicians to drug allergies and medical conditions. The physician could have independently assessed those for relevancy. However, when the EHR system is the set up to be the central source of truth for things like drug allergies, it may produce a high frequency of notifications that impedes efficient care," says Dr. Whittington. "In this case, the EHRs capacity to store endless information on patient, clinical and pharmaceutical information becomes a barrier instead of a benefit."
Solution
While CMS' Stage 2 proposed rule begins to address this issue, Dr. Whittington believes that physician input is critical for solving the problem. "There are nuances in the [CMS Stage 2 proposed] rule that address the need for physician input on the importance of notifications. This is great because physician and clinician input is critical," says Dr. Whittington. However, beyond federal regulations, hospitals need to include physicians in EHR system implementation so that only the necessary alerts are included.
4. Treatment for wrong patients. Due to the complexity of EHRs, physicians commonly enter information or order tests for the wrong patient, which can lead to inefficient and inaccurate healthcare. According to Dr. Whittington, this problem is not new to the healthcare industry. Back in the days of paper charts, it was possible to write on the wrong patient chart and order a treatment for the wrong patient, and EHRs make it easier for physicians to make that mistake. "Learning and using an EHR is very complex. It is easy to end up on the wrong screen without realizing. While there are lots of emerging technologies designed to combat this problem, it still exists and is dangerous," says Dr. Whittington.
Solution
A hospital needs to fix its operations before it implements an EHR system. The problem of physician inaccuracy will not go away when an EHR is installed. If the EHR implementation has already begun, adding physician and clinician involvement may help. "Optimizing the EHR and continuously verifying the EHR is used properly by staff is important. The hospital cannot implement the EHR, train the employees for a few months and expect everything to change," says Dr. Whittington. Regular check-ins with hospital staff on EHR usage and understanding is important.
5. Lack of test-results follow-up. Physicians can be lulled into a sense of comfort that the EHR system will catch potentially overlooked follow-up items, which causes them to lose their vigilance with patient follow-up. "All too often healthcare providers assume that the installation of an EHR or the automation of a process will solve problems with follow-up and follow through at a hospital. We often forget that automating a bad process means you still have a bad process," says Dr. Whittington. Assuming that an EHR system will solve issues in hospital operations and quality outcomes may actually lead to worse outcomes.
Solution
The lack of test-results follow-up is another example of the necessity for hospitals to fix operational problems before implementing EHRs. "The EHR is not a magic bullet for problems at the hospital," says Dr. Whittington. The solution to this problem comes from optimizing the EHR with training follow-ups and check-ins, optimization teams and physician input.
HIT can offer the healthcare industry improvements in patient safety, work processes and patient outcomes. However, when hospitals poorly implement EHRs and never optimize the systems, negative consequences may result. These consequences could hurt patients and lead to inpatient mortality. Solutions range from industry wide initiatives to specific hospital tasks, which should be used in order to increase the effectiveness and benefits of HIT.
Hospitals Need Additional IT Infrastructure to Fix HIT Issues, Frustrations
Using HIT to Drive Clinical Integration, Patient and Physician Engagement and Population Health Management
1. Patient care delay. According to Dr. Whittington, much of a hospital or health system's patient information is decentralized on EHR systems, which can delay patient care. "As a hospital moves to an EHR, not all the data is incorporated and transferred at the same time. Half the information could be electronic and half could still be hard copies in a binder. This makes it difficult for physicians to find all the information they need in one search," says Dr. Whittington. This decentralization of information makes physicians hunt for the information they need, which delays diagnosis, treatment and recovery. For example, patient weight in one part of a record may not duplicate to other places, causing the physician to search for information needed for drug dosing. Each minute a physician searches for information could mean the difference between a positive and negative health outcome.
Solution
Dr. Whittington believes that there needs to be a bigger push for patient-centric EHRs to address problems with decentralized information. "The push for interoperability and health information exchange in CMS' Stage 2 meaningful use proposed rule is a good start, but more could be done," says Dr. Whittington.
2. Unnecessary tests and studies. Many EHR systems are not standardized which makes heath information exchange across providers more difficult and may lead to unnecessary tests and studies. For example, depending on the EHR system, a radiology report could represent as an image, a table or a graph. If a physician is used to seeing a radiology report as an image and a different provider's report presents as a table, the physician could misinterpret the report and order an unnecessary test. "If a physician works in hospital A and needs to order a test for a patient, that physician should be able to look at patient's record and know if hospital B did that test also. If that study was done, a second test is a waste of time, energy and resources," says Dr. Whittington. When tests are unnecessarily duplicated, it lengthens an individual's treatment and raises costs.
Solution
Dr. Whittington recommends a slightly radical solution — standardizing EHRs similar to how the banking and financial industry standardized bank routing numbers. "My view is that we need an affordable, one size fits all system. The more uniformity we have in our HIT the better. For instance, every bank has a routing number and they are all similar. There is no differentiation among routing numbers. That is the type of standardization the healthcare industry needs," says Dr. Whittington.
3. Disregarding vital information. Physicians and clinicians often develop alarm fatigue when using EHRs, and ignoring alarms and potentially overlooking vital information could lead to negative patient outcomes. Many EHRs have alarms for drug allergies, patient history and medication combinations. However, when physicians and clinicians receive alerts and distracting notifications, they may override them. This alarm fatigue could cause them to miss an important notification because many unimportant ones flashed first. "On a paper chart, there may have been red stickers alerting physicians to drug allergies and medical conditions. The physician could have independently assessed those for relevancy. However, when the EHR system is the set up to be the central source of truth for things like drug allergies, it may produce a high frequency of notifications that impedes efficient care," says Dr. Whittington. "In this case, the EHRs capacity to store endless information on patient, clinical and pharmaceutical information becomes a barrier instead of a benefit."
Solution
While CMS' Stage 2 proposed rule begins to address this issue, Dr. Whittington believes that physician input is critical for solving the problem. "There are nuances in the [CMS Stage 2 proposed] rule that address the need for physician input on the importance of notifications. This is great because physician and clinician input is critical," says Dr. Whittington. However, beyond federal regulations, hospitals need to include physicians in EHR system implementation so that only the necessary alerts are included.
4. Treatment for wrong patients. Due to the complexity of EHRs, physicians commonly enter information or order tests for the wrong patient, which can lead to inefficient and inaccurate healthcare. According to Dr. Whittington, this problem is not new to the healthcare industry. Back in the days of paper charts, it was possible to write on the wrong patient chart and order a treatment for the wrong patient, and EHRs make it easier for physicians to make that mistake. "Learning and using an EHR is very complex. It is easy to end up on the wrong screen without realizing. While there are lots of emerging technologies designed to combat this problem, it still exists and is dangerous," says Dr. Whittington.
Solution
A hospital needs to fix its operations before it implements an EHR system. The problem of physician inaccuracy will not go away when an EHR is installed. If the EHR implementation has already begun, adding physician and clinician involvement may help. "Optimizing the EHR and continuously verifying the EHR is used properly by staff is important. The hospital cannot implement the EHR, train the employees for a few months and expect everything to change," says Dr. Whittington. Regular check-ins with hospital staff on EHR usage and understanding is important.
5. Lack of test-results follow-up. Physicians can be lulled into a sense of comfort that the EHR system will catch potentially overlooked follow-up items, which causes them to lose their vigilance with patient follow-up. "All too often healthcare providers assume that the installation of an EHR or the automation of a process will solve problems with follow-up and follow through at a hospital. We often forget that automating a bad process means you still have a bad process," says Dr. Whittington. Assuming that an EHR system will solve issues in hospital operations and quality outcomes may actually lead to worse outcomes.
Solution
The lack of test-results follow-up is another example of the necessity for hospitals to fix operational problems before implementing EHRs. "The EHR is not a magic bullet for problems at the hospital," says Dr. Whittington. The solution to this problem comes from optimizing the EHR with training follow-ups and check-ins, optimization teams and physician input.
HIT can offer the healthcare industry improvements in patient safety, work processes and patient outcomes. However, when hospitals poorly implement EHRs and never optimize the systems, negative consequences may result. These consequences could hurt patients and lead to inpatient mortality. Solutions range from industry wide initiatives to specific hospital tasks, which should be used in order to increase the effectiveness and benefits of HIT.
More Articles on HIT Implementation:
How to Improve EHR Performance With Clinical Best PracticesHospitals Need Additional IT Infrastructure to Fix HIT Issues, Frustrations
Using HIT to Drive Clinical Integration, Patient and Physician Engagement and Population Health Management