Inadequate training of staff and clinicians is a common problem encountered when an electronic medical record (EMR) is implemented. The following case study illustrates how poor training can impede the operations of the physician's office and even lead to patient safety issues. A successful training strategy will avoid these types of problems by ensuring the staff and clinicians are knowledgeable about proper EMR use and that the staff who are responsible for configuring and maintaining the EMR are skilled and working as a team.
Case Study: A multi-office practice has used an EMR for 18 months. Mary, an office manager with project management and IT experience, is the primary caretaker of the EMR. She has struggled with two other office managers who want to have the same access she has to configure the EMR. Their argument is that they know what’s best for their offices and that Mary is too busy to meet their needs. Mary argues that she is not too busy, but that instead it takes time to properly test and manage changes made to the EMR. Their arguments are taken to the physician’s EMR oversight group who ask Mary to just “let it go” and provide the access those office managers need.
One week later Mary was suddenly inundated with trouble calls. Physicians were unable to enter diagnosis codes and their staff unable to work claims. Mary called the two office managers who swore they had not done anything wrong. One of them, whose office was having no problems, admitted that she did add several diagnosis codes to a template because her doctor wanted them. Mary subesequently discovered that she had failed to link all of the other physicians to the new template which is why her office was the only one with no problems. Mary fixed this issue, but then decided to run an audit to see if any other changes had been made to the EMR without communication or notices. She indeed discovered a change the other office manager made to a parameter called “Allergy Severity Default” with the default answer changed from “Severe” to “Mild”. Mary knew about a “quirk” with this EMR whereby it fails to trigger an allergy alert if the allergy is entered as “Mild”. She had previously taken the issue to the physician oversight group who determined that the answer in this field must default to “Severe” when physicians enter an allergy. They felt it was a patient safety risk if every time a physician entered an allergy they also had to actively change the default answer to “Severe”.
When Mary explained this, the office manager replied that her physician claimed a “Severe” allergy is one where anaphylactic shock occurs and that he was tired of always changing the answer from “Severe” to “Mild”. Mary changed the default answer back to “Severe”, asked the EMR physician oversight group to re-educate the physicians and began working with the EMR vendor to completely remove “Mild” as an available answer. The vendor complied promptly.
• The most common source of problems with using EMRs is inadequate training
Case studies of EMR implementations, whether successful or failed, consistently list “training” as a key factor for success. Ongoing educational reminders, especially for “work-arounds” and unique issues as exemplified in this case, are often useful.
• Be wary of “work-arounds”
“Work-arounds” are encountered because people creatively develop ways, especially manual ones, to work around technology when it obstructs them from doing something. Be wary of EMR work-arounds and make sure they are the best solution to the problem. In retrospect, completely removing “Mild” as an option in this case would have been a better initial solution instead of the work-around that was developed.
• Resolving EMR-related patient safety issues is a shared responsibility between the physician and EMR vendor
Work collaboratively with the EMR vendor and prioritize issues for them. If ten issues are reported but only one of them is a patient safety issue, prioritization will focus the vendor’s resources on the important issue. Mary immediately notified and educated the vendor about the patient safety issue in this case.
• Proactive management of EMR changes will reduce the number of EMR-related problems
There are standardized “change management” practices that minimize the risk of unexpected EMR problems. These proactive practices ensure that each change is adequately tested, approved and communicated in advance. Advance communication of an EMR change should indicate who, what, where, when and why changes are being made. This provides an opportunity for critical feedback.
• Effective communication is essential for safe patient care
Poor interpersonal relationships and the lack of effective communication among staff directly contributed to the problems in this case. Discussion of the proposed changes would have allowed Mary or others to intervene and avoid the problems entirely.