Study Links EHR Usability Issues to Potential Patient Harm

March 28, 2018
Specific types of electronic health record (EHR) usability issues are associated with a variety of potentially serious patient harm events, according to a new study published this week.

Specific types of electronic health record (EHR) usability issues are associated with a variety of potentially serious patient harm events, according to a new study published this week.

The usability and interoperability of electronic health records (EHRs) continue to be a source of frustration for clinicians, however, according to a group of researchers, specific usability issues and EHR processes that may be linked to possible patient harm across different health care facilities have not been identified.

EHR usability is the extent to which EHRs support clinicians in their work. Researchers, led by Raj Ratwani, Ph.D., director of the National Center for Human Factors in Healthcare, MedStar Health in Washington, D.C., sought to study EHR usability and the potential contribution to patient harm. The researchers examined reports of potential patient harm, from 2013 through 2016, that explicitly mentioned a major EHR vendor or product. The study was published in the Journal of the American Medical Association this week.

Specifically, the researchers examined 1.735 million free-text patient safety reports, which are self-reported by clinicians, from 571 healthcare facilities in Pennsylvania and from a large mid-Atlantic multi-hospital academic healthcare system. Only reports that used one of the top five electronic health products or vendors, and that were classified as "reaching the patient with possible harm," were included.

The researchers found that, of the reported safety events, 1,956 of them, or 0.11 percent, specifically mentioned an EHR vendor or product and were reported as possible patient harm and 557, or 0.03 percent, had language suggesting the usability of the EHR may have contributed to some possible patient harm.

According to a MedStar Health press release, Dr. Ratwani, lead author, said, “There’s no question that electronic health records have clear benefits for clinicians and patients, and can improve the care process. However, nearly all healthcare systems have adopted an EHR and this technology has introduced some new risks to patient safety, as our study has shown. Our view is that even one patient harm event that stems from EHR usability issues is unacceptable. These are solvable issues, and we are committed to improving EHR usability and patient safety.”

The study identified patient harm scenarios involving seven categories of usability, including data entry, alerting and interoperability. The usability challenges were associated with four types of clinical processes, including order entry placement and medication administration. Examples include:

Order PlacementA physician put medication orders in the EHR while a patient was in post-surgical recovery, and soon thereafter left the hospital. Though the orders appeared complete, the orders were never activated, causing the nursing staff to question whether the orders had been discontinued.

System Automation and DefaultsA physician enters a patient’s blood-thinner medication to start at a specific time of day on October 1, but the EHR defaulted to October 2, which the doctor did not realize until the order has been pushed through.

AlertsThe EHR failed to fire an alert about a drug allergy, even though the patient’s allergy was listed in the record.

Researchers focused on reports that explicitly mentioned one of the top-five EHR vendors (by market share) and reportedly resulted in patient harm. The analysis identified a) if a usability issue was involved, and if so, what it was, and b) the clinical process that was involved in the safety event.

The researchers noted that one of the limitations of the study is that patient safety reports contain limited information, making it difficult to identify causal factors. The reports also may be subject to bias, inaccuracies and a tendency to attribute blame for an event to the EHR.

Ratwani and the research team concluded that the research reinforces the need for collaboration across all stakeholders in the development, implementation and oversight of EHRs. This action includes the call for greater collaboration between EHR vendors and providers to improve design and use, implementation of oversight policies as defined in the 21st Century Cures Act and development of additional research into usability and safety challenges looking at a broader sample.