ONC: Clinicians must recognize when EHRs create unsafe conditions

Electronic health record users know that health IT can help enhance patient care, but many still don't recognize that the "unintended consequences" of using EHRs also can cause adverse patient events, speakers said during a webinar produced by the Office of the National Coordinator for Health IT on Jan. 10. The webinar was based on a guide issued by ONC in November 2013 to help identify and address patient care mishaps that could be attributable to EHRs.

"They see the misdiagnosis or near miss but [not] the role of health IT in the problem," warned attorney Kathy Kenyon, a senior policy analyst for ONC. Since clinicians and risk managers don't see the role of health IT in adverse events, they don't report its involvement, she added.  

ONC is working with the Joint Commission and others to educate clinicians about the possible role of health IT in creating unsafe conditions for patients. The top health IT related adverse events stem from system interface issues, wrong data input, wrong record retrieved, and software functionality or configuration issues.

"These are not [all] unique to EHRs. It can happen with paper. But in EHRs [the error] can automatically populate another field," said Karen Zimmer, Medical Director for the ECRI Institute.

Organizations can better identify health IT-related incidents and take steps to reduce them, such as better monitoring, changing an organization's reporting systems to identify when health IT may be a factor, and supporting a culture that encourages staff reporting of health IT-related events, added Cynthia Wallace, a senior risk management analyst at ECRI Institute.

The speakers recommended that providers use tools from the Agency of Health Research and Quality to collect health IT-related adverse event information and report such events to patient safety organizations. They also called for EHR developers to "team up" with others to improve patient safety.

"Health IT related errors, if unaddressed, will undermine the goal of improving patient care," Zimmer said.

EHR-related patient safety issues have been recognized as a concern. HHS recently issued a health IT safety action plan to attempt to resolve some of these issues and the HIMSS EHR Association released a code of conduct.

To learn more:
- here are the webinar slides