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Patient Safety Tip
of the Week
March 24, 2020
Mayo Clinic: How to
Get Photos in Your EMR
Patient misidentification has been a topic of many of our columns.
We’ve long been advocates of including patient photographs in the EMR as a
means of reducing patient identification errors. And there are many other
benefits of having patient photographs in the EMR.
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” showed a glaring example of how patient
photographs in the EMR might prevent a wrong patient error. It also described
the mechanical steps one hospital uses to get patient photographs into the EMR.
In a study by Blanchfield et al. (Blanchfield 2019) the
patient photographs were taken when the patient presented to the ED. The ease
with which we can today take a digital photograph today and upload it to the
EHR enables the use of up-to-date patient photos. In the Blanchfield
study, they created a new standard of care and implemented a new workflow for
ED registration staff. Using iPod touch devices, ED registration staff took
photos of consenting patients either at the front desk when patients check-in,
or at the end of the registration process.
But having the equipment and a
protocol is the easy part. Actually, achieving
a goal of getting photos in all patient EMR’s is more complicated. A study from
the Mayo Clinic (Aseem 2020)
is informative in that regard. A survey of all physicians practicing in their
executive medicine division showed overwhelming support of respondents (92.3%)
for inclusion of a patient photograph in the upper left corner of the EMR to
help them in responding to phone messages and other issues of patient care.
But, before they began a quality improvement intervention, the mean weekly
measurement of the rate of photograph inclusion in the EMR was only 49.5%.
Their multidisciplinary quality improvement team set a goal of increasing the
rate of photo inclusion in the EMR by 20%, with a target rate of 70% or greater
within 6 months of intervention.
They describe 3 PDSA cycles, each lasting 6 to 9 weeks. In
the first, they gave visual cue cards to patients. The cards reinforced the
importance of having a picture in their medical record to aid in proper
identification, while addressing potential privacy concerns. It also gave them
options to get the photos into the EMR.
The second PDSA cycle involved face-to-face meetings between
the clinical staff and front office staff. This resulted in changes to workflow
that made it easier to capture a patient photograph at the time of check-in for
their medical appointment.
The third PDSA cycle focused on feedback and encouragement.
Weekly results were shared in clinical staff meetings, on a notice board, and
in the form of a poster. Barriers
to implementation were discussed and all encouraged ideas to
streamline workflow. Encouragement was passed back on to staff to continue with
their improved process.
After the first cycle, the photograph inclusion rate
increased from 49.5% to 59.4%. After the second cycle, the rate increased to a
peak of 74.7%, but then began to regress toward previous levels, After the
third cycle, the rate remained relatively static at 76.0%. Overall, after 3
PDSA cycles, the mean weekly rate of patient photographs included in the EMR
was 71.4%, meeting their original goal.
The article includes a nice graphic representation of the
results on a weekly basis. It demonstrates 2 important elements: first, you
will see some week-to-week variation in rates and, second, quality improvement
projects need to be monitored for sustainability of results.
Some barriers were noted. These were patients in an
executive medicine clinic, many of whom “seek to maintain a low profile” or
were otherwise concerned with privacy issues.
They also concluded that the intervention can be implemented
inexpensively and without significant impact on workflow.
Note that the study did not measure the
ultimate goal: reduction in patient misidentification
errors. If you were to implement such a project in your organization, you might
use the RAR (Retract-and-Reorder) methodology (see our July 17, 2012 Patient
Safety Tip of the Week “More
on Wrong-Patient CPOE”) to identify instances where a user
initially entered an order on the wrong patient. The RAR methodology is also
nicely described in the supplement to the Adelman study (Adelman
2019) that we referenced in our May 21, 2019 Patient Safety Tip of the Week “Mixed
Message on Number of Open EMR Records”. It is a tool we’ve recommended you
use in tracking and monitoring patient misidentification issues as part of your
quality improvement program (see our March
26, 2019 Patient Safety Tip of the Week “Patient Misidentification”). The RAR methodology, of course, measures
near misses (by definition, it identifies instances where the user recognized
the error and corrected it). But it is one of the only proxies we have for
assessing the frequency of potential wrong-patient ordering errors.
Our June 26, 2012 Patient Safety Tip
of the Week “Using
Patient Photos to Reduce CPOE Errors” described how Children’s Hospital of
Colorado successfully implemented use of patient photographs to reduce CPOE
errors (Hyman
2012). Beginning with
a nice review of the literature on patient-note mismatches, they implemented
tools to help avoid such mismatches during CPOE. First, they modified their
CPOE workflow to include a verification screen asking the provider to verify
that this is the patient on whom he/she intends to enter orders. They then
began taking photographs of patients at admission or registration and including
these on the above noted verification screen. They found a dramatic reduction
in the number of events of actual ordering on the wrong patient or near-misses.
And when such events or near-misses did occur, it was usually in charts that
did not have a photograph of the patient. While they could not separate out the
impact of the verification screen from that of the photograph, they felt that
the photographs played a large role in reducing the number of orders placed in
the records of wrong patients. They noted that, unlike other CPOE alerts that
have a high likelihood of being ignored, the presence of the large centrally
placed photograph is effective in capturing the attention of the CPOE user.
They did note that photographs have limitations, particularly for newborns and
when pictures are poorly exposed. And they note that photographs need to be
updated at appropriate times.
The Blanchfied study mentioned
above (Blanchfield 2019)
demonstrated that a passive display of patient photos in the EHR was associated
with reduced rates of wrong patient orders and near misses in the Brigham and
Women’s Emergency Department. While the study looked at how having patient
photos in the EHR helped physicians identify the correct patient when entering
orders in the EHR, one can readily see how having the photo at the top of every
screen (in the EHR or the radiology PACS system), along with their name and DOB
and medical record number, would help whomever is searching for an image
identify the correct patient.
What could go wrong? The biggest risk would be that the
photo could be inadvertently be put into the EMR of the wrong patient. Staff
inputting the photos obviously need to comply with 2-factor patient
identification. A double check would not be practical for those offices with
only a single receptionist and would likely be fraught with error in busy
reception areas. But, for those EMR systems that provide patient access, you
might ask the patient to confirm their photo is the correct one.
Some have questioned whether photos in the EMR might enable
fraud. Actually, using photos in the EMR probably is a
deterrent to fraud. Someone fraudulently using the ID of another patient would
now likely be recognized as not being the intended patient.
People’s appearances change as they age and their appearance may also change for
other reasons. They change their hair color or hair length, they lose their
hair, they get new glasses, they get facial surgery, etc. So that raises the
issue of when and how patient photographs should be taken. Your organization
should have a policy on how often or under what other circumstances you should require
a new photo. Most DMV’s require a new photo every 2 years or so when you renew
your driver’s license. Your front office staff might also play a role in
spotting cases where a new photo should be taken. Many front office staff get
popup screens when registering patients that ask useful questions like “Do you
have a current advance directive?”. You could easily add a question about
whether there is an up-to-date photo.
There is also something to be said about real-time photographs
in certain settings. Our November 12, 2019 Patient Safety Tip of the Week “Patient Photographs Again
Help Radiologists” showed how real-time photographs, taken at the
same time a radiology study was being done, were of great value not only in
identifying the correct patient but also improving the clinical information
available to the radiologist. And, in the Blanchfield
study (Blanchfield 2019) the
patient photographs were taken when the patient presented to the ED. The ease
with which we can today take a digital photograph today and upload it to the
EHR enables the use of up-to-date patient photos. In the Blanchfield
study, they created a new standard of care and implemented a new workflow for
ED registration staff. Using iPod touch devices, ED registration staff took
photos of consenting patients either at the front desk when patients check-in,
or at the end of the registration process.
Could facial recognition software eventually play a role?
One might anticipate someone calling in to an office might have their identity
verified via facial recognition on a cell phone or computer, with matching
occurring against the photo in the EMR. Just a thought… That might lead to more
confusion given the current state of the art, but who knows in the future? And
you’d have to figure out what would happen with identical twins.
The Mayo system was thought to be especially helpful when
clinicians were talking to patients on the phone (the photo reminding them
about the patient). We think the most important value of the photo is when you
search on a patient name in the EMR and the EMR truncates to the first result
meeting the search criteria. You then have the opportunity of seeing a photo
that may tell you it’s the wrong patient.
There, of course, are other benefits to having patient
photographs in the EMR. In our July 28, 2009 Patient Safety Tip of the Week “Wandering,
Elopements, and Missing Patients” we briefly mentioned using
photographs of patients when broadcasting an alert for a missing patient. We
recommend that you include in your IT system a digital photograph of patients
you identify as being at risk for wandering and elopement. Many communities,
often in conjunction with their local chapter of the Alzheimer Association,
have programs where families provide photos of their relatives with Alzheimer’s
Disease or other dementia to the local police department to facilitate searches
when such individuals go missing.
Inclusion of patient photographs would be a logical tool to
use in avoiding wrong patient surgeries or mix ups in medication
administration. In fact, there are programs that have used patient photographs
to reduce the risk of patient misidentification during medication
administration (AHRQ
Health Care Innovations Exchange). The JPS Health Network in Fort
Worth, Texas implemented such a system on its psychiatry units. They first
implemented it on adolescent psychiatry in 2000 then, based on success of that
program, extended it to their adult psychiatry service in 2006. They noted that
this additional method of correct patient identification is especially needed
on psychiatry because patients frequently remove their wristband
identifications and may be unable or unwilling to respond to questions at the
time of medication administration. In the year after implementation on the
adult unit, there were no misidentification errors on either unit. Reappearance
of misidentification errors a year later led to a reeducation effort and such
errors again fell to almost zero.
Radiologists have also found patient photographs to be
helpful. In our December 2008 What’s New in the Patient Safety World “Patient
Photographs Improve Radiologists’ Performance” we noted a
paper presented at the Radiological Society of North America’s annual meeting
showing that inclusion of photographs of patients improved accuracy of
radiologists’ reports. Putting a photograph of the patient aside their images
on a PAC screen resulted not only in the radiologists feeling more empathy
toward the patient but they also identified more incidental findings (the files
were chosen because of incidental findings in this randomized study) without
taking more time to review the images.
Another study (Ridley
2012) demonstrated that including patient photographs in PACS
systems likely leads to fewer misidentification errors. Researchers at Emory
University developed a low-cost system for obtaining patient photographs at the
time an imaging procedure was being done and integrating them via wireless
connection with the images going to their PACS system. They then gave
radiologists imaging studies to read that purposefully including some instances
of misidentification. Those reading without patient photographs picked up only
12.5% of the misidentified patients. Those reading with the patient photographs
detected 64% of the errors.
Our November 12, 2019 Patient Safety Tip of the Week “Patient Photographs Again
Help Radiologists” showed how real-time photographs, taken at the
same time a radiology study was being done, were of great value not only in
identifying the correct patient but also improving the clinical information
available to the radiologist. Another article detailed how digital photographs
can be integrated with medical imaging studies (Ramamurthy
2013).
So, it’s pretty clear that use of patient photographs has an
important role in multiple aspects of patient safety. The current Mayo Clinic
study provides some useful guidance on how your organization can promote the
use of patient photos in the EMR.
Some of our prior columns on use of patient photographs
in patient safety:
December 2008 “Patient Photographs Improve
Radiologists’ Performance”
January 12, 2010 “Patient
Photos in Patient Safety”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic
Identification to Prevent Errors”
January 19, 2016 “Patient
Identification in the Spotlight”
March 26, 2019 “Patient
Misidentification”
November 12, 2019 “Patient Photographs Again
Help Radiologists”
December 17, 2019 “Tale of Two Tylers”
Some of our prior
columns related to patient identification issues:
May 20, 2008 “CPOE Unintended Consequences – Are Wrong
Patient Errors More Common?”
November 17, 2009 “Switched
Babies”
July 17, 2012 “More on Wrong-Patient CPOE”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic
Identification to Prevent Errors”
August 2015 “Newborn Name Confusion”
January 12, 2016 “New Resources on Improving Safety of
Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
August 1, 2017 “Progress
on Wrong Patient Orders”
June 19, 2018 “More
EHR-Related Problems”
November 2018 “More
on Hearing Loss”
March 26, 2019 “Patient
Misidentification”
May 21, 2019 “Mixed Message on Number of
Open EMR Records”
September 10, 2019 “Joint Commission Naming
Standard Leaves a Gap”
December 17, 2019 “Tale of Two Tylers”
References:
Blanchfield BB, Salmaisian H,
Landman A. Abstract #56. Adding Patient Photos to the Electronic Health Record
to Improve Patient Identification and Reduce Wrong Patient Order Errors. Ann Emerg Med 2019; 74(4s): S22-23 October 2019
https://www.annemergmed.com/article/S0196-0644(19)30733-4/fulltext
Aseem
S, Ratrout BM, Litin SC, et
al. A Process of Acceptance of Patient Photographs in Electronic Medical
Records to Confirm Patient Identification. Mayo Clinic Proceedings:
Innovations, Quality & Outcomes 2020; 4(1): 99-104
https://mcpiqojournal.org/article/S2542-4548(19)30152-3/fulltext
Adelman JS,
Applebaum JR, Schechter CB, et al. Effect of Restriction of the Number of
Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order
Errors. A Randomized Clinical Trial. JAMA 2019; 321(18): 1780-1787
https://jamanetwork.com/journals/jama/fullarticle/2733207
Hyman D, Laire M, Redmond D, Kaplan DW. The use of patient pictures
and verification screens to reduce computerized provider order entry errors.
Pediatrics 2012; 130(1): e211-e219
https://pediatrics.aappublications.org/content/130/1/e211?download=true
AHRQ Health Care.
Innovations Exchange. Innovation Profile: Use of Photographs
as Second Means of Identifying Patients on Psychiatry
Units Virtually Eliminates Medication Errors Related
to Misidentification. Last Updated: 10/09/2013
Ridley EL.
Integrating digital photos within PACS may cut ID errors. AuntMinnie.com June
20, 2012
Ramamurthy S, Bhatti
P, Arepalli CD, Salama M, Provenzale
JM, Tridandapani S. Integrating patient digital
photographs with medical imaging examinations. J Digit Imaging 2013; 26(5):
875-885
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3782605/pdf/10278_2013_Article_9579.pdf
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