Setting national goals to bolster patient safety with electronic health records

Their report appears in the current issue of the New England Journal of Medicine.

Proposed framework

"One of the reasons electronic health records were introduced was because we wanted to make health care safer, more efficient and of higher quality," said Dr. Hardeep Singh, assistant professor of medicine and health services research at the Veterans Affairs Health Services Research and Development Center of Excellence and BCM. "However, electronic health records present new hazards that were brought in with the use of technology and were not seen before. In this paper, we propose a framework that addresses three types of intersections between patient safety and electronic health records."

Those three intersections include making sure that the EHR technology is itself safe, the application and use of the EHR technology is safe and the EHR technology is used to monitor and improve patient safety.

Dr. Dean Sittig, professor at the UTHealth School of Biomedical Informatics and a member of the UTHealth-Memorial Hermann Center for Healthcare Quality and Safety, uses the analogy of driving a car. First, you want to be sure that the car is safe, i.e., that your brakes and headlights are working. Next, you want to be sure that you are driving the car safely. That means you are not texting and driving, you have both hands on the wheel and your seatbelt is buckled. Finally, with newer cars, technology makes driving safer, as in when backup cameras serve as "eyes" in the back of your head. In essence, the car is making your driving experience safer.

"That's what we want from electronic health records," said Sittig.

Hazards unique to technology

To account for variation in stages of EHR implementation across clinical practice settings, Sittig and Singh propose that goals should first address safety hazards unique to technology (i.e. safer EHRs in phase 1). Phase 2 goals should mitigate safety hazards from failure to use technology appropriately (i.e. safer application and use of EHRs); and phase 3 goals should stimulate the use of technology in order to monitor and improve patient safety (i.e. leveraging EHRs to detect all types of hazards and facilitating oversight).

Health care groups using electronic health records should start with phase 1, ensuring that the technology is safe to use, said Singh and Sittig. That includes making sure the technology is fast enough to ensure acceptable system response time and there is a data backup in the case of a loss or corruption of the main data store. In phase 2, the groups should make sure that electronic health records are being used appropriately. Some organizations mix paper records and electronic records, which can result in not only extra work but also confusion and risky scenarios when doctors and nurses have to refer to two different records.

"We suggest that organizations should use electronic health records 'completely' rather than partially. It should be the only way to practice medicine in hospitals," said Sittig.

Consistent use of technology

In some cases, hospitals allow physicians on some units to use paper for orders while other units require that orders be entered through electronic health records, a potential hazard. He suggests the technology should be used consistently for the same purpose rather than haphazardly, which creates a lack of clarity.

Finally, organizations should address phase 3 to improve patient safety by better measurements.

For example, they said, the computer could monitor risky situations within a system and identify potential problems. In some cases, the computer could alert someone that there were abnormal lab results from last month that have not been reviewed yet.

"You cannot reach high levels of patient safety without using the computer and without paying attention to the requirements of these three phases," they said.

"Electronic health records are changing the way we practice medicine and deliver health care," said Singh. "Some of our recommendations are provided to ensure that you get the maximum benefits of EHRs. We want the EHR-enabled health system to be safer and far more effective than the paper-enabled health system."