Other than studies coming from a few pioneering academic medical centers with home grown EMR’s, convincing evidence for a beneficial effect of EMR’s on patient safety has been scant. But a new study using data from the Pennsylvania Patient Safety Authority (PPSA) and the HIMSS Analytics database demonstrates a substantial decrease in patient safety events at hospitals with advanced EMR’s (Hydari 2014). Advanced EMR’s were those in which CPOE and physician documentation had been implemented (as opposed to basic EMR’s which have a clinical data repository and clinical decision support). The researchers found that advanced EMRs led to a 27 percent decline in patient safety events overall, driven by a 30 percent decline in events due to medication errors and 25 percent decline in events due to complications of tests, treatments and procedures. The results remained robust after adjustment for multiple factors such as hospital case mix, patient demographics, teaching status, hospital size, etc.
A strength of the study is that all Pennsylvania hospitals report patient safety events to the PPSA database. On the other hand, data in the HIMSS database is self-reported by hospitals and may not be completely accurate. You’ll also need an advanced degree in biostatistics to understand all the nuances of their “robustness” checks!
But the data are very encouraging and seem to confirm our longstanding faith that EMR’s would eventually deliver, at least on the patient safety side of the equation (the fiscal side may be a different story).
When used well, the data from electronic medical records can be extremely helpful for quality and patient safety. Alerts and reminders generated on algorithms using clinical and laboratory elements in the EMR need to be validated, evidence-based, have good sensitivity and specificity, and be actionable or provide alternative options, and be delivered to the person most likely to perform the appropriate intervention (the latter not always being the physician).
In our November 11, 2014 Patient Safety Tip of the Week “Early Detection of Clinical Deterioration” we noted how use of data from electronic sources can was able to detect clinical deterioration early and reduce mortality rates. Another new study demonstrated that an early warning and response system for sepsis resulted in a significant increase in early sepsis care, ICU transfer, and sepsis documentation (Umscheid 2014). There was also a trend toward decreased sepsis mortality and increased discharge to home that did not reach statistical significance. The system was based on laboratory values and vital signs from the electronic health record monitored in real time. If a patient had ≥4 predefined abnormalities at any single time, the provider, nurse, and rapid response coordinator were notified and performed an immediate bedside patient evaluation. And we’ve done several columns on use of decision support tools to avoid Torsade de Pointes (see our June 10, 2014 Patient Safety Tip of the Week “Another Clinical Decision Support Tool to Avoid Torsade de Pointes”.
But not everyone is using EMR’s to their fullest extent and there continue to be unexpected consequences of EMR’s.
In fact, ECRI Institute has recently released its annual report on the Top 10 Health Technology Hazards and “Data Integrity: Incorrect or Missing Data in EHRs and Other Health IT Systems” is #2 on the list for 2015. Among the examples the report identifies in this category are:
Way back when we first began participating in EMR implementations we recognized the risks of entering information or orders into the wrong patient’s record (see our May 20, 2008 “Montefiore News Release 2014).”). We continue to see systems in which a physician can have more than one patient’s medical record online simultaneously (for example, one might have one patient’s imaging report showing in a radiology PACS system and another patient’s record showing on a CPOE screen). It’s easy to see how such “wrong patient” errors can occur in those circumstances. In fact, this problem is so prevalent that AHRQ has just awarded a substantial grant to study the problem (
Even well-intentioned EMR-related projects may result in unintended consequences. A recent case report showed how trying to fit a standardized order set into an inflexible EMR resulted in serious consequences to patients (Manley 2014). Recognizing that continuous bladder irrigation (sometimes used for patients with gross hematuria and a few other conditions) was being managed more and more by staff not very familiar with its use, standardized order sets were developed. Such irrigation is typically done via low gravity so that pressure inside the bladder does not rise to dangerous levels. Because the EMR would not accept infusions without specifying rates, those developing the order set felt the orders would be similar to IV orders and require rates in the order. Staff began bladder infusions using infusion pumps, resulting in bladder rupture in at least one patient. The report goes on to describe how a multidisciplinary team analyzed cases and worked collaboratively to develop a good standardized order set.
And, of course, we continue to see that many EMR’s have notes of various providers in silos such that they are seldom read by others (see our October 2014 What’s New in the Patient Safety World column “Ebola Exposes Fundamental Flaw”).
These are but a few examples of the downside of the EMR. Below are listed some of our prior columns on the unintended consequences of EMR’s. But the recent study using the PPSA database (Hydari 2014) is encouraging and suggests that we are finally turning the corner on fulfilling the promise of EMR’s to improve patient safety.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
Hydari MZ, Telang R, Marella WM. Saving Patient Ryan - Can Advanced Electronic Medical Records Make Patient Care Safer? (September 30, 2014). Available at SSRN:
Umscheid CA, Betesh J, VanZandbergen C, et al. Development, implementation, and impact of an automated early warning and response system for sepsis. J Hosp Med 2014; Article first published online: 26 SEP 2014
ECRI Institute. ECRI Institute 2015 Top 10 Health Technology Hazards. A Report from Health Devices. November 2014
Montefiore News Release. AHRQ Grant Awarded to Study the Impact of Health IT on Patient Safety at Montefiore and Einstein and Brigham and Women’s Hospital. September 24, 2014
Manley BJ, Gericke RK, Brockman JA, et al. The pitfalls of electronic health orders: development of an enhanced institutional protocol after a preventable patient death. Patient Safety in Surgery 2014, 8: 39
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