The evolution of the electronic medical record (EMR) has resulted in major changes in the healthcare environment. As early as 2009, Congress was allocating funds ($19 billion) to promote the use of EMRs, and EMRs are a major component of the Affordable Care Act.
As orthopaedic surgeons, we each have individual stories and experiences with EMRs—both favorable and unfavorable. However, little emphasis has been placed on the potential effects on patient safety resulting from the use of EMRs. The perceived potential for compromise in patient safety is serious enough that the American Medical Informatics Association (AMIA) has suggested creating an adverse event reporting system to investigate and report on adverse events and medical errors specifically related to EMR use.
EMRs have the potential to affect safety in several different areas. A few of these potential safety issues include distraction, inhibition of communication, data entry errors, and time consumption that removes the provider from patient contact.
The very nature of hardware and software design lends itself to the potential for errors in the clinical setting. Most programs require the completion of a fixed sequence of steps to progress through the record. This is true for both data entry and order input (Computer Physician Order Entry-CPOE). Many programs require a direct and timely response from the user. To proceed through the sequence, the user must focus on the task at hand. In the clinical setting, this task fixation may be distracting and hamper communication with both patients and team members.
Distraction, communication, and safety
Preparing the medical record and documenting care, by their very nature, require the provider to focus on the EMR rather than the patient. The design of the EMR, however, may compound that distraction. Just as distracted drivers may lead to automobile crashes, distracted providers, busy with data input, may have the potential to be a safety issue in the clinical setting.
Communication is one of the six Cs of surgical safety. This is an area that the AAOS has targeted to increase patient and provider satisfaction, improve patient compliance, and decrease liability risks. The distractions associated with computer use certainly hamper communication. Focus on the screen necessarily removes focus from the patient. The clinician may miss the subtle clues from patients—body language, facial expressions, and changes in tone during a conversation—that can help direct a diagnosis or call attention to a problem.
In addition, the check boxes involved in information input may prevent the clinician from asking the valuable open-ended questions that we all learned in medical school. The time component associated with entering patient data is longer than conventional data recording, which reduces both communication and time spent in patient interactions.
Use of EMRs may result in less conventional, face-to-face contact with patients and may reduce engagement with patients. This reduction in engagement may influence the clinician’s perception of the patient’s agenda, which may be either a positive or negative influence on the patient’s care. A focus on data may preclude attention to any personal or social factors involved in the patient’s care or the effects of care on the patient’s life and family. The presence of a computer screen and the distraction associated with collection of data may cause many of these important communicated nuances to be missed.
User or input errors, particularly those associated with CPOE, are of particular concern. Incorrect or missing data may be perpetuated and many programs do not flag that data error or absence. If the errors can be found, a process for their correction may be created, but most providers may not know an error has occurred. Although these errors also occur with paper record, the ubiquity of the EMR and the ability to ‘cut-and-paste’ means they may permeate the entire system. In addition, a Leapfrog Group study found that many EMR systems failed to alert doctors to issues such as medical allergies or drug interactions during CPOE as much as one-third of the time.
Despite the government’s desire to have EMR systems that communicate with each other, interoperability remains an issue. Hundreds of companies sell EMR systems that do not or cannot communicate with each other. Incorrect, incomplete, or ‘dropped’ data become part of the record as result of these miscommunications.
What can be done?
With the delineation of the problem, there may be some answers. Simply being aware of the problem, particularly as it applies to distraction and communication issues, can lead physicians to acquire skills that could mitigate potential safety incidents.
For example, to lessen the potential effects of distraction, physicians could postpone computer interactions until less critical phases of a procedure. Communication skills, already critical in patient interaction and healthcare team coordination, can be refined through training. Things as simple as engaging the patient to help input medical information in the EMR can not only increase interaction with the physician but also prevent incorrect data entry.
In their position paper addressing the usability of EMR systems, the AMIA has provided fourteen principles to aid in the design of and increase the usability of EMR systems. Several of the principles are pertinent to patient safety, including a call for minimalist design, or the design of the system specifically directed toward the clinical user’s goal. In theory, this would decrease time input and distraction.
Informative feedback and useful error messages could decrease input errors. The ability to reverse actions could also decrease input errors and save time. To prevent incomplete or ineffective order entry, a check before placing the order can be implemented.
Clear business models exist in software development. Software designers create conceptual models based on specific input by potential end users. As the architecture of the system and software evolves, there is continual testing by users and necessary changes are made. The preliminary product is then beta tested in practice before the final product is released for use. Unfortunately, many EMR systems were not developed using this model and have limited physician input in their design.
According to a January 2015 position paper by the American College of Physicians, the electronic clinical record is in danger of being overloaded with extraneous data that has the potential to be detrimental to patient care. In addition, in March 2015, The Joint Commission issued a potential serious adverse event statement associated with EMR.
Physicians rely on their training and experience to provide quality patient care in a safe setting. We should not allow the gains that we have made in patient safety to be lost by the implementation of EMR technology.
Joe B. Wilkinson, MD, is a member of the AAOS Patient Safety Committee.
- Stahel PF, Mauffrey C, Butler N: Current challenges and future perspectives for patient safety in surgery. Patient Saf Surg 2014;8(1):9. http://www.pssjournal.com/content/8/1/9
- Hurlbert SN, Garrett J:. Improving operating room safety. Patient Saf Surg 2009;3(1):25. doi:10.1186/1754-9493-3-25 This article is available from: http://www.pssjournal.com/content/3/1/25
- Robb, WJ: Orthopaedic Surgery Safety Update 2012. AAOS Fall Meeting Presentation.
- Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304(15):1693-1700. doi:10.1001/jama.2010.1506
- Young-Xu Y, Neily J, Mills PD, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg 2011;146(12):1368-1373. doi:10.1001/archsurg.2011.762