Digitized Medicine

Case Study:   During the failed resuscitation attempt of a premature newborn in a neonatal intensive care unit (NICU) a nurse discovered the child was receiving 100 times the proper dose of heparin.  An immediate review of all 35 NICU patients revealed three others had heparin IV overdoses running.  These were stopped and those patients suffered no adverse effects.  An immediate investigation by the hospital’s Sentinel Event Rapid Response Team discovered a series of missteps that unfortunately aligned despite the presence of multiple preventative systems and processes including computerized physician order entry (CPOE).  The critical error turned out to be an erroneous heparin overdose order in a “Neonatal Admissions” order set.  Order sets that include medication orders at this hospital must be approved by the Pharmacy and Therapeutics Committee (P&T).  P&T had previously approved the order set, but on the morning of the incident the Medical Director of the NICU had called IT and requested that several non-pharmacy orders immediately be added to the order set.  The purpose of these new orders was to capture additional data needed for a monthly neonatology quality report that is electronically sent to a national database and used for quality benchmarking.  The clinical IT analyst did not think the order set needed to go back to P&T because there were no new pharmacy orders.  However, this EMR requires the analyst to re-enter the entire order set when making any changes.  The analyst made a decimal point error when keying in the Heparin order.  No other clinician reviewed, tested or reviewed the change.

Key Points:

• Inaccurate or inconsistent clinical content in an EMR is a risk to patient safety and automation can propagate such errors to multiple patients before being discovered and corrected

Physicians and their staff will develop or customize clinical content for parts of their EMR such as order sets, documentation templates, physician orders and discharge instructions.  This case serves as a brutal reminder for the need to be very attentive to the accuracy of clinical content in an EMR.  The tragic outcome in this case was initiated by a type of human error (a “typo”) that can be anticipated and prevented by oversight processes.  

• Physicians should oversee the processes used to manage and monitor the development of clinical content

Physicians will usually be called on to be the “authors” of EMR clinical content for items they are most knowledgeable about such as the documentation templates and order sets they will use.  Ideally the physician will develop content that is evidence-based and collaborate with others in the practice to avoid conflicting content and to reduce variations in care.  But physicians should also oversee the processes used to manage and monitor the development of other clinical content as well.  Similar to the hospital P&T committee, a physician or physician group should review and approve new or changed content before it is put into their EMR.  Content should also be reviewed by the authors at least annually to keep it up-to-date.

• Physicians should work with their EMR vendor to assure that the clinical content in their EMR meets the emerging state and federal vocabulary standards for content

Vocabulary standards define how an EMR “encodes” clinical data which facilitates the ability of EMRs to reliably exchange that data with other systems.  In other words, if two EMRs use the same definition of “Gestational Age” and encode that measurement in the same way, those EMRs will be able to exchange that data (“talk” with each other) reliably.  In this case the neonatologists were adding an order to capture “Gestational Age” in the EMR to meet a new vocabulary standard determined by their specialty’s national quality benchmarking entity.  Some state and federal vocabulary standards exist, but more are forthcoming with the HITECH “meaningful use” requirements driving them forward.

It is not uncommon to find physician groups who use the same version of the same electronic medical record (EMR) product but with significantly different degrees of satisfaction.  How can this be?  The following case study illustrates how successful EMR implementations leverage the capabilities of the EMR to streamline work flow and achieve specific goals.  This is the second of six case studies being used to describe the safe use of EMRs.

Work Flow and Communications Case Study:

A pediatric group in the final stages of selecting an EMR product sent their “physician champion” on site visits to two similar practices who had implemented identical versions of the same EMR.  At the first site visit the physicians are very pleased with the EMR and describe how clinical decision support tools help them achieve their goals.  For instance, during an 8 month-old Well Child visit the EMR defaults in a developmental history template that prompts age-appropriate questions.  With a single click on the order button an order set with routine orders for an 8 month-old Well Child visit displays.  The orders are completed in 30 seconds.  The pediatricians proudly tout the weight-based dosing option that calculates medication doses based on the patient’s current weight.

At the second site the physicians, parents and staff grumble about “going electronic” and complain about how long it takes to enter orders.  The visiting physician gains much insight while observing an 8 month-old Well Child visit.  The physicians rarely make eye contact with the parents as they struggle to find age-appropriate developmental screening questions from a long pick-list of questions they had built on a single developmental history template used for all patients.  They order each immunization, test and prescription separately.  Each test requires at least 5 clicks, three screens and a lot of scrolling.   They also manually calculate medication doses and type them onto the e-prescribing screen.   It takes several minutes to complete the orders.   When you ask why they don’t use the EMR’s weight-based dosing option, they reply that they discovered the weight-based dosing function is not safe to use.

Key Points:

• Successful EMR implementations leverage the capabilities of the EMR to streamline work flow and achieve specific goals

Most EMRs have at least some features that can be designed and configured to work in different ways, or not used at all, such as order sets, documentation templates, health care maintenance tools and other clinical decision support tools.  Understanding these capabilities and designing optimal ways to leverage them are critical for successful EMR implementations.  The first group knew their goals and designed the EMR to achieve them.  They were particularly adept at leveraging the EMR’s capabilities to streamline work flow.  The second group, on the other hand, is floundering with poor work flows and no apparent goals for the EMR other than “going electronic”.

• Automation of inefficient paper-based processes is a common risk to avoid

In the first office the physicians consider weight-based dosing to be a real time-saver and patient safety enhancement, but the second office considers it to be a patient safety risk.  It turns out that in the second office the nurse opens up and uses a single documentation template to enter documentation during the entire patient visit just like she did with paper records.  She keeps this template “open” because it takes too much time to submit part of the documentation, then re-open it to document more, then submit, re-open and so on.  So when the physicians used the weight-based dosing option, “today’s” weight would not display because the nurse had not yet submitted that data.  Thus, their poor work flow design and lack of synchronization not only slowed them down, but created a patient safety issue if the weight-based dosing option was used.  In the first office they avoided this by designing a “Vital Signs” template that the nurse used at check-in.  After the vital signs were entered into the template and “submitted” by the nurse the next logical documentation template conveniently popped-up to use. This group had used an IT consultant to help them redesign their work flow to take advantage of a paper-less environment.

• EMRs can interfere with physician-patient and physician-nurse communications

The lack of eye contact noted by patients in the second office is an example of how EMRs can impede communications in healthcare settings. It is prudent to be aware of the potential for such communication problems and to consider ways to avoid them.

I am using six case studies to illustrate that most EMR-related problems, even those involving hardware and software, can usually be traced back to some controllable factors.   The safe and meaningful use of EMRs is facilitated by leveraging these controllable factors to minimize these problems.