Lack of real-world EHR testing causes patient safety problems, experts say

EHR tests fail to incorporate usability issues that confuse clinicians and, as a result, sometimes cause errors. (Getty Images/PRImageFactory)

Electronic health records (EHRs) have frustrated physicians for years, causing confusion and workflow challenges. In extreme scenarios, they can even cause patient harm.

While implementation and training play a role, a new analysis from the Pew Charitable Trusts, MedStar Health’s Center for Human Factors in Healthcare, and the American Medical Association says EHRs aren’t being tested properly in the first place. And the organizations are advocating for The Joint Commission to build some of the report's recommendations into its accreditation program.

The Office of the National Coordinator for Health Information Technology (ONC) requires EHR developers to test their software for end-user engagement and usability. But the regulator does not provide vendors guidelines for assessing what safety issues might arise from clinical use.

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While some vendors test their products for patient safety anyway, these test cases do not always reflect realistic clinical conditions or custom changes to a program.

The report provided the following as a test case scenario that lacks rigor: “Looking at patient John Leeroy’s record, enter a new lab order for the patient.” This scenario does not specify the lab order or reflect the complexities of clinical care.

RELATED: Study finds EHR implementation still taking too much time, causing serious errors

Plus, this question would identify selecting any lab order as a success, so it does not legitimately evaluate whether the EHR would cause usability or safety issues.

The authors say tests should reflect the way the technology is used by doctors and nurses, contain clinically oriented goals and success metrics, and include challenging tasks that, if not tested, could cause workflow problems.

“EHR safety requires engagement from both the vendor and the provider,” according to Raj Ratwani, Ph.D., scientific director and senior research scientist of the National Center for Human Factors in Healthcare at MedStar's Institute for Innovation, one of the report's authors. This analysis is unique because it considers both of those groups’ perspective, rather than just vendors, he added.

RELATED: Interoperability report: This is how office-based physicians are using EHRs

The report includes an appendix with 14 “test cases” that realistically reflect a user’s clinical environment by incorporating seven main usability issues: accessibility, alerting, default settings, data entry, visual clutter, interoperability and workflow support.

“These test cases can be used immediately by vendors and providers,” Ratwani said. He noted they were developed based on a prior analysis that used more than 1.7 million patient safety reports.

The authors have shared the report “with organizations that can leverage these findings to reduce patient harm,” according to Ben Moscovitch, project director of health IT at The Pew Charitable Trusts, who also authored the report. But they have also called on the industry's top accreditor to take a larger role.

“The Joint Commission could adapt the best practices in this report into its accreditation requirements to ensure that hospitals and other facilities are factoring safety and usability into system customization, implementation, and deployment," Moscovitch said. 

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