The electronic health record: An essential tool for advancing patient safety

Abstract

According to a recent American Hospital Association survey, 68% of US hospitals reported they had fully or partially implemented electronic health records in 2006.1RWF News Digest. Available at: http://www.rwjf.org/portfolios/features/digest.jsp?iaid=142&id=5134&c=EMC-ND142. Accessed March 10, 2007.Google Scholar The adoption of the electronic health record has resulted in numerous improvements to support patient quality and safety.2Smith K. Smith V. Krugman M. Oman K. Evaluating the impact of computerized clinical documentation.Comput Inform Nurs. 2005; 23: 132-138Crossref PubMed Scopus (99) Google Scholar, 3Bates D.W. Gawande A.A. Improving safety with information technology.N Engl J Med. 2003; 348: 2526-2534Crossref PubMed Scopus (1082) Google Scholar, 4Mekhjian H.S. Kuman R.R. Kuehn L. Bentley T.D. Teater P. Thomas A. et al.Immediate benefits realized following implementation of physician order entry at an academic medical center.J Am Med Inform Assoc. 2002; 9: 529-539Crossref PubMed Scopus (302) Google Scholar To be sure, the benefits from this technology are only beginning to be realized.Notable improvements have been identified in practice standardization, decision support, communication, and data capture for management, research, and quality monitoring.2Smith K. Smith V. Krugman M. Oman K. Evaluating the impact of computerized clinical documentation.Comput Inform Nurs. 2005; 23: 132-138Crossref PubMed Scopus (99) Google Scholar, 4Mekhjian H.S. Kuman R.R. Kuehn L. Bentley T.D. Teater P. Thomas A. et al.Immediate benefits realized following implementation of physician order entry at an academic medical center.J Am Med Inform Assoc. 2002; 9: 529-539Crossref PubMed Scopus (302) Google Scholar, 5Pronovost P.J. Miller M.R. Wachter R.M. Tracking progress in patient safety: An elusive target.JAMA. 2006; 296: 696-699Crossref PubMed Scopus (146) Google Scholar These advances—particularly in the integration of patient care standards, the creation of alerts for clinical interventions that are out-of-standard or incomplete, and data management systems—can be related to improvements in patient quality and safety.6Institute of MedicineKohn L.T. Corrigan J.M. Donaldson M.S. To err is human: Building a safer health system. National Academy Press, Washington, DC2000Google ScholarThe electronic health record is now used by patients, caregivers, and researchers to achieve the following goals:•Collaborate and clearly identify patient care needs,•Document and communicate those needs to all team members in real time,•Create an integrated plan of care,•Integrate evidence-based clinical standards and evidence-based principles within documentation templates,•Identify expected outcomes, and finally to•Evaluate the processes and outcomes of care.While these goals of collaboration, communication, planning, integrating evidence-based standards, outcome management, and evaluation of processes and value are not new to healthcare professionals, they can now be more fully and realistically achieved with the electronic record.Three specific applications within the electronic record—computerized physician order entry (CPOE), electronic medication administration records (eMAR), and clinical documentation—are impacting patient safety in numerous ways by decreasing incorrect and unnecessary treatments and medications, as well as improving the timeliness of care.2Smith K. Smith V. Krugman M. Oman K. Evaluating the impact of computerized clinical documentation.Comput Inform Nurs. 2005; 23: 132-138Crossref PubMed Scopus (99) Google Scholar, 4Mekhjian H.S. Kuman R.R. Kuehn L. Bentley T.D. Teater P. Thomas A. et al.Immediate benefits realized following implementation of physician order entry at an academic medical center.J Am Med Inform Assoc. 2002; 9: 529-539Crossref PubMed Scopus (302) Google Scholar, 7Tourville J. Automation and error reduction: How technology is helping Children’s Medical Center of Dallas reach zero-error tolerance.US Pharm. 2003; 28: 80-86Google Scholar The benefits from these 3 applications vary, depending on the implementation sequence; some organizations implement each application as separate initiatives, while other organizations have implemented all 3 applications simultaneously.Decreases in incorrect and unnecessary treatments and medicationsWith all electronic applications, the problem of illegible handwriting is eliminated. Also eliminated is the time required for clarification of illegible and incomplete orders. Transcription is no longer required and orders are expedited to other departments. Patient care needs are now communicated more clearly and more quickly for all clinicians.The embedding of pathways, rules, and alerts into the electronic record has served to guide practitioners in selecting the most appropriate course of action and desired goals. The use of embedded clinical pathway standards or rules also provides suggestions for drug selections and dosages based on research and contemporary evidence. Real-time safety surveillance with these tools provides guidance for all clinicians involved in providing patient care. Physicians, nurses, pharmacists, therapists, and nutritionists all benefit from the pathways and rules. These standards serve to minimize or eliminate treatment selection errors and inappropriate provider orders, and they also serve to request clarification of orders when indicated.3Bates D.W. Gawande A.A. Improving safety with information technology.N Engl J Med. 2003; 348: 2526-2534Crossref PubMed Scopus (1082) Google Scholar Clinical pathways also alert providers to interventions not previously considered and, thereby, decrease the potential for missed interventions.Alerts, or the signaling of critical information in the electronic record, inform the provider of the need to clarify, validate and/or change the selected intervention (an intervention that has been identified as out of the normal range, less effective than other medications, or inconsistent with the patient condition). One example of the use of the alert for patient safety is the integration of research-based risk factor interventions in the electronic record specific to patient mobility. The “patient mobility” or “patient risk for fall” alerts signal the need for implementation and continual monitoring of patients at risk for falls or any other identified areas of risk.Decreases in treatment delaysThe electronic record provides for simultaneous multi-user access, real-time communication and transmission of orders to other disciplines, and a focused and structured hands-off process. This improvement in communication has also improved the patient care experience by decreasing the redundant data collection.8Meadows G. Improving the patient experience with information technology.Nurs Econ. 2003; 21: 300-301PubMed Google Scholar Communication devices such as wireless communicators and clinician locator badges have linked the providers, the patient, the record, and health care work more tightly. Costly delays in locating and accessing other clinicians are nearly eliminated with the array of devices that are now available. In essence, virtual, multidisciplinary care planning and evaluation of that care now occurs nearly simultaneously by all members of the team. Patient care processes are facilitated, and patient discharge from the setting are expedited.We have only just begunNumerous opportunities still exist with the electronic record to improve patient safety. There are opportunities to collect, sort, and analyze data in volumes and types that were not previously possible:•All documented data specific to the patient, rather than selected data (convenience or purposive samples), are now available for analysis.•Patient errors can now be analyzed in context (i.e., in consideration of patient factors, medical conditions, nursing needs, etc.). Multiple variables that are involved in patient errors specific to the provider, practice standards, patient variables, and the system can now be taken into consideration in the resolution of errors. The individual provider is no longer the only source of an error. With this rich and robust database of information, early remediation of errors can now occur as well as protocol modification, thus preventing future similar errors.•Data specific not only to errors but also the degree of quality provided can be now extracted from the electronic record. One example is the analysis of the adequacy of pain management during the course of treatment. Questions can now be raised about the provision of the correct and appropriate treatment and the adequacy of the treatment.•Providers are able to analyze the sequence of events in an episode of care leading up to the error and begin to intervene at the earliest possible stage, correct system breakdowns, and move alerts to an earlier time in the processes of care.•Real-time, customized reports of compliance can be generated.•Interventions with minor deviations that do not result in patient harm can be identified, analyzed, and used to modify standards. Also, data differentiating side effects from adverse events can be analyzed to determine efficacy and safety.•Data specific to the cost of care and the cost of errors can be continually examined and refined.Issues still remainWhile the implementation of the electronic record has resulted in significant improvements in patient safety, it is not a single panacea for all medical errors; rather, it is a supporting tool that requires an organizational culture of safety and an awareness of the new generation of errors that are emerging. Screen design, data entry errors, and changes in communication that minimize face time are new and different events that will require analysis and new solutions.First and foremost, an underlying organizational culture of safety must be present and actively reinforced. Emphasis on high reliability systems using redundancy, high level teamwork, and avoidance of punitive approaches to errors by organizations is foundational to advance patient safety and the tools designed to support it.There is no failsafe system to assure that provider orders and clinical documentation are entered on the correct patient record. It is still possible to document on the wrong patient. Patient identification technology and processes are in their infancy stages. The linkage between the electronic record and the “physical” patient is not yet failsafe.Systems are designed to allow caregivers to override alerts and rules in the case of an emergency. All system overrides must be carefully analyzed and controlled. Behaviors that reinforce safety and accountability require that clinicians override systems only in an emergency.Application interoperability remains an obstacle that challenges the best of programmers and interface specialists. Integrating both clinical and management application data systems for patient identification, intravenous fluid management, automated medication administration, prescription writing, workload management, and productivity are in the infancy stage at best.Extraction of data from the electronic record and creation of useful reports has been difficult. Creating queries for data still requires significant time and expertise.Fully integrated lifetime patient records in a format that can be examined, manipulated, and monitored to best understand the uniqueness of the patient and avoid errors is still needed for all citizens. To be sure, the advances in patient care using the electronic medical record are significant in improving patient safety and much is still to be gained from future improvements and innovations. According to a recent American Hospital Association survey, 68% of US hospitals reported they had fully or partially implemented electronic health records in 2006.1RWF News Digest. Available at: http://www.rwjf.org/portfolios/features/digest.jsp?iaid=142&id=5134&c=EMC-ND142. Accessed March 10, 2007.Google Scholar The adoption of the electronic health record has resulted in numerous improvements to support patient quality and safety.2Smith K. Smith V. Krugman M. Oman K. Evaluating the impact of computerized clinical documentation.Comput Inform Nurs. 2005; 23: 132-138Crossref PubMed Scopus (99) Google Scholar, 3Bates D.W. Gawande A.A. Improving safety with information technology.N Engl J Med. 2003; 348: 2526-2534Crossref PubMed Scopus (1082) Google Scholar, 4Mekhjian H.S. Kuman R.R. Kuehn L. Bentley T.D. Teater P. Thomas A. et al.Immediate benefits realized following implementation of physician order entry at an academic medical center.J Am Med Inform Assoc. 2002; 9: 529-539Crossref PubMed Scopus (302) Google Scholar To be sure, the benefits from this technology are only beginning to be realized. Notable improvements have been identified in practice standardization, decision support, communication, and data capture for management, research, and quality monitoring.2Smith K. Smith V. Krugman M. Oman K. Evaluating the impact of computerized clinical documentation.Comput Inform Nurs. 2005; 23: 132-138Crossref PubMed Scopus (99) Google Scholar, 4Mekhjian H.S. Kuman R.R. Kuehn L. Bentley T.D. Teater P. Thomas A. et al.Immediate benefits realized following implementation of physician order entry at an academic medical center.J Am Med Inform Assoc. 2002; 9: 529-539Crossref PubMed Scopus (302) Google Scholar, 5Pronovost P.J. Miller M.R. Wachter R.M. Tracking progress in patient safety: An elusive target.JAMA. 2006; 296: 696-699Crossref PubMed Scopus (146) Google Scholar These advances—particularly in the integration of patient care standards, the creation of alerts for clinical interventions that are out-of-standard or incomplete, and data management systems—can be related to improvements in patient quality and safety.6Institute of MedicineKohn L.T. Corrigan J.M. Donaldson M.S. To err is human: Building a safer health system. National Academy Press, Washington, DC2000Google Scholar The electronic health record is now used by patients, caregivers, and researchers to achieve the following goals:•Collaborate and clearly identify patient care needs,•Document and communicate those needs to all team members in real time,•Create an integrated plan of care,•Integrate evidence-based clinical standards and evidence-based principles within documentation templates,•Identify expected outcomes, and finally to•Evaluate the processes and outcomes of care. While these goals of collaboration, communication, planning, integrating evidence-based standards, outcome management, and evaluation of processes and value are not new to healthcare professionals, they can now be more fully and realistically achieved with the electronic record. Three specific applications within the electronic record—computerized physician order entry (CPOE), electronic medication administration records (eMAR), and clinical documentation—are impacting patient safety in numerous ways by decreasing incorrect and unnecessary treatments and medications, as well as improving the timeliness of care.2Smith K. Smith V. Krugman M. Oman K. Evaluating the impact of computerized clinical documentation.Comput Inform Nurs. 2005; 23: 132-138Crossref PubMed Scopus (99) Google Scholar, 4Mekhjian H.S. Kuman R.R. Kuehn L. Bentley T.D. Teater P. Thomas A. et al.Immediate benefits realized following implementation of physician order entry at an academic medical center.J Am Med Inform Assoc. 2002; 9: 529-539Crossref PubMed Scopus (302) Google Scholar, 7Tourville J. Automation and error reduction: How technology is helping Children’s Medical Center of Dallas reach zero-error tolerance.US Pharm. 2003; 28: 80-86Google Scholar The benefits from these 3 applications vary, depending on the implementation sequence; some organizations implement each application as separate initiatives, while other organizations have implemented all 3 applications simultaneously. Decreases in incorrect and unnecessary treatments and medicationsWith all electronic applications, the problem of illegible handwriting is eliminated. Also eliminated is the time required for clarification of illegible and incomplete orders. Transcription is no longer required and orders are expedited to other departments. Patient care needs are now communicated more clearly and more quickly for all clinicians.The embedding of pathways, rules, and alerts into the electronic record has served to guide practitioners in selecting the most appropriate course of action and desired goals. The use of embedded clinical pathway standards or rules also provides suggestions for drug selections and dosages based on research and contemporary evidence. Real-time safety surveillance with these tools provides guidance for all clinicians involved in providing patient care. Physicians, nurses, pharmacists, therapists, and nutritionists all benefit from the pathways and rules. These standards serve to minimize or eliminate treatment selection errors and inappropriate provider orders, and they also serve to request clarification of orders when indicated.3Bates D.W. Gawande A.A. Improving safety with information technology.N Engl J Med. 2003; 348: 2526-2534Crossref PubMed Scopus (1082) Google Scholar Clinical pathways also alert providers to interventions not previously considered and, thereby, decrease the potential for missed interventions.Alerts, or the signaling of critical information in the electronic record, inform the provider of the need to clarify, validate and/or change the selected intervention (an intervention that has been identified as out of the normal range, less effective than other medications, or inconsistent with the patient condition). One example of the use of the alert for patient safety is the integration of research-based risk factor interventions in the electronic record specific to patient mobility. The “patient mobility” or “patient risk for fall” alerts signal the need for implementation and continual monitoring of patients at risk for falls or any other identified areas of risk. With all electronic applications, the problem of illegible handwriting is eliminated. Also eliminated is the time required for clarification of illegible and incomplete orders. Transcription is no longer required and orders are expedited to other departments. Patient care needs are now communicated more clearly and more quickly for all clinicians. The embedding of pathways, rules, and alerts into the electronic record has served to guide practitioners in selecting the most appropriate course of action and desired goals. The use of embedded clinical pathway standards or rules also provides suggestions for drug selections and dosages based on research and contemporary evidence. Real-time safety surveillance with these tools provides guidance for all clinicians involved in providing patient care. Physicians, nurses, pharmacists, therapists, and nutritionists all benefit from the pathways and rules. These standards serve to minimize or eliminate treatment selection errors and inappropriate provider orders, and they also serve to request clarification of orders when indicated.3Bates D.W. Gawande A.A. Improving safety with information technology.N Engl J Med. 2003; 348: 2526-2534Crossref PubMed Scopus (1082) Google Scholar Clinical pathways also alert providers to interventions not previously considered and, thereby, decrease the potential for missed interventions. Alerts, or the signaling of critical information in the electronic record, inform the provider of the need to clarify, validate and/or change the selected intervention (an intervention that has been identified as out of the normal range, less effective than other medications, or inconsistent with the patient condition). One example of the use of the alert for patient safety is the integration of research-based risk factor interventions in the electronic record specific to patient mobility. The “patient mobility” or “patient risk for fall” alerts signal the need for implementation and continual monitoring of patients at risk for falls or any other identified areas of risk. Decreases in treatment delaysThe electronic record provides for simultaneous multi-user access, real-time communication and transmission of orders to other disciplines, and a focused and structured hands-off process. This improvement in communication has also improved the patient care experience by decreasing the redundant data collection.8Meadows G. Improving the patient experience with information technology.Nurs Econ. 2003; 21: 300-301PubMed Google Scholar Communication devices such as wireless communicators and clinician locator badges have linked the providers, the patient, the record, and health care work more tightly. Costly delays in locating and accessing other clinicians are nearly eliminated with the array of devices that are now available. In essence, virtual, multidisciplinary care planning and evaluation of that care now occurs nearly simultaneously by all members of the team. Patient care processes are facilitated, and patient discharge from the setting are expedited. The electronic record provides for simultaneous multi-user access, real-time communication and transmission of orders to other disciplines, and a focused and structured hands-off process. This improvement in communication has also improved the patient care experience by decreasing the redundant data collection.8Meadows G. Improving the patient experience with information technology.Nurs Econ. 2003; 21: 300-301PubMed Google Scholar Communication devices such as wireless communicators and clinician locator badges have linked the providers, the patient, the record, and health care work more tightly. Costly delays in locating and accessing other clinicians are nearly eliminated with the array of devices that are now available. In essence, virtual, multidisciplinary care planning and evaluation of that care now occurs nearly simultaneously by all members of the team. Patient care processes are facilitated, and patient discharge from the setting are expedited. We have only just begunNumerous opportunities still exist with the electronic record to improve patient safety. There are opportunities to collect, sort, and analyze data in volumes and types that were not previously possible:•All documented data specific to the patient, rather than selected data (convenience or purposive samples), are now available for analysis.•Patient errors can now be analyzed in context (i.e., in consideration of patient factors, medical conditions, nursing needs, etc.). Multiple variables that are involved in patient errors specific to the provider, practice standards, patient variables, and the system can now be taken into consideration in the resolution of errors. The individual provider is no longer the only source of an error. With this rich and robust database of information, early remediation of errors can now occur as well as protocol modification, thus preventing future similar errors.•Data specific not only to errors but also the degree of quality provided can be now extracted from the electronic record. One example is the analysis of the adequacy of pain management during the course of treatment. Questions can now be raised about the provision of the correct and appropriate treatment and the adequacy of the treatment.•Providers are able to analyze the sequence of events in an episode of care leading up to the error and begin to intervene at the earliest possible stage, correct system breakdowns, and move alerts to an earlier time in the processes of care.•Real-time, customized reports of compliance can be generated.•Interventions with minor deviations that do not result in patient harm can be identified, analyzed, and used to modify standards. Also, data differentiating side effects from adverse events can be analyzed to determine efficacy and safety.•Data specific to the cost of care and the cost of errors can be continually examined and refined. Numerous opportunities still exist with the electronic record to improve patient safety. There are opportunities to collect, sort, and analyze data in volumes and types that were not previously possible:•All documented data specific to the patient, rather than selected data (convenience or purposive samples), are now available for analysis.•Patient errors can now be analyzed in context (i.e., in consideration of patient factors, medical conditions, nursing needs, etc.). Multiple variables that are involved in patient errors specific to the provider, practice standards, patient variables, and the system can now be taken into consideration in the resolution of errors. The individual provider is no longer the only source of an error. With this rich and robust database of information, early remediation of errors can now occur as well as protocol modification, thus preventing future similar errors.•Data specific not only to errors but also the degree of quality provided can be now extracted from the electronic record. One example is the analysis of the adequacy of pain management during the course of treatment. Questions can now be raised about the provision of the correct and appropriate treatment and the adequacy of the treatment.•Providers are able to analyze the sequence of events in an episode of care leading up to the error and begin to intervene at the earliest possible stage, correct system breakdowns, and move alerts to an earlier time in the processes of care.•Real-time, customized reports of compliance can be generated.•Interventions with minor deviations that do not result in patient harm can be identified, analyzed, and used to modify standards. Also, data differentiating side effects from adverse events can be analyzed to determine efficacy and safety.•Data specific to the cost of care and the cost of errors can be continually examined and refined. Issues still remainWhile the implementation of the electronic record has resulted in significant improvements in patient safety, it is not a single panacea for all medical errors; rather, it is a supporting tool that requires an organizational culture of safety and an awareness of the new generation of errors that are emerging. Screen design, data entry errors, and changes in communication that minimize face time are new and different events that will require analysis and new solutions.First and foremost, an underlying organizational culture of safety must be present and actively reinforced. Emphasis on high reliability systems using redundancy, high level teamwork, and avoidance of punitive approaches to errors by organizations is foundational to advance patient safety and the tools designed to support it.There is no failsafe system to assure that provider orders and clinical documentation are entered on the correct patient record. It is still possible to document on the wrong patient. Patient identification technology and processes are in their infancy stages. The linkage between the electronic record and the “physical” patient is not yet failsafe.Systems are designed to allow caregivers to override alerts and rules in the case of an emergency. All system overrides must be carefully analyzed and controlled. Behaviors that reinforce safety and accountability require that clinicians override systems only in an emergency.Application interoperability remains an obstacle that challenges the best of programmers and interface specialists. Integrating both clinical and management application data systems for patient identification, intravenous fluid management, automated medication administration, prescription writing, workload management, and productivity are in the infancy stage at best.Extraction of data from the electronic record and creation of useful reports has been difficult. Creating queries for data still requires significant time and expertise.Fully integrated lifetime patient records in a format that can be examined, manipulated, and monitored to best understand the uniqueness of the patient and avoid errors is still needed for all citizens. To be sure, the advances in patient care using the electronic medical record are significant in improving patient safety and much is still to be gained from future improvements and innovations. While the implementation of the electronic record has resulted in significant improvements in patient safety, it is not a single panacea for all medical errors; rather, it is a supporting tool that requires an organizational culture of safety and an awareness of the new generation of errors that are emerging. Screen design, data entry errors, and changes in communication that minimize face time are new and different events that will require analysis and new solutions. First and foremost, an underlying organizational culture of safety must be present and actively reinforced. Emphasis on high reliability systems using redundancy, high level teamwork, and avoidance of punitive approaches to errors by organizations is foundational to advance patient safety and the tools designed to support it. There is no failsafe system to assure that provider orders and clinical documentation are entered on the correct patient record. It is still possible to document on the wrong patient. Patient identification technology and processes are in their infancy stages. The linkage between the electronic record and the “physical” patient is not yet failsafe. Systems are designed to allow caregivers to override alerts and rules in the case of an emergency. All system overrides must be carefully analyzed and controlled. Behaviors that reinforce safety and accountability require that clinicians override systems only in an emergency. Application interoperability remains an obstacle that challenges the best of programmers and interface specialists. Integrating both clinical and management application data systems for patient identification, intravenous fluid management, automated medication administration, prescription writing, workload management, and productivity are in the infancy stage at best. Extraction of data from the electronic record and creation of useful reports has been difficult. Creating queries for data still requires significant time and expertise. Fully integrated lifetime patient records in a format that can be examined, manipulated, and monitored to best understand the uniqueness of the patient and avoid errors is still needed for all citizens. To be sure, the advances in patient care using the electronic medical record are significant in improving patient safety and much is still to be gained from future improvements and innovations.