Hospital clinicians’ EHR 'workarounds' pose risk to patient safety and quality, study finds

hospital EHR
Workarounds “pose a threat to quality of care and patient safety,” the researchers said, with the potential for clinicians to overlook important information that could result in a lack of synchronization between care team members. (Sergey Tinyakov/GettyImages)

Frustrated with the design and usability of inpatient electronic health record (EHR) systems, hospital care teams frequently use handwritten notes and verbal comments to communicate patient information, posing a threat to patient safety and the quality of care, a study finds.

In a recent study published in PLOS, researchers found widespread frustration and concerns among hospital clinicians about the design and usability of EHRs, particularly with the handoff process. Care teams also voiced frustration with how information is accessed and presented in EHRs.

The study, which focused on the use of an Epic EHR system at a major teaching hospital, also found a high degree of variance in how clinicians use EHRs during morning rounds—most used the EHR before entering the patients’ room but only sometimes in the room. Only about half of attending clinicians, residents, interns and physician assistants use the EHR after leaving the patients’ room, the study found.

“If the information was presented in a more user-friendly way, then maybe we can have it up. I don't have to be as focused on trying to find a piece of information that I need to progress the patient's care,” one attending said, according to the researchers.

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For the study, researchers evaluated EHR use during morning rounds, conducted interviews with clinicians and other end users and also surveyed clinicians about how EHRs support their workflow.

Hospital clinicians frequently "work around" the formal EHR process, including the use of handwritten notes to document patient information, the study found. Clinicians also relayed important information about patients via emails and verbal conversations when handing off patients between care teams.

Many clinicians said handwritten notes were more useful than using the EHR during rounds and handwriting was a better cognitive aid to process and remember patient information, according to the study.

However, these workarounds “pose a threat to quality of care and patient safety,” the researchers said, with the potential for clinicians to overlook important information that could result in a lack of synchronization between care team members.

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“When the EHR is not used in the room, patients’ data is not necessarily accurate,” lead researcher Shiri Assis-Hassid told FierceHealthcare. “What we saw is that the care team prints out the patient summary report, at the beginning of morning rounds, and some information, such as test results, are not necessarily updated by the time they get to the patient’s room; they don’t have the most recent information.”

The study includes a photo showing a patient summary report with handwritten notes scribbled in the margins. “A picture is worth a thousand words,” Assis-Hassid said, noting that many studies on EHR use are quantitative studies and “miss the full picture of how it affects the care teams’ workflow.”

Use of handwriting on patient summary report during rounds (PLOS One/Shiri Assis-Hassid)

“What you can see there is that there is no order, you don’t know what goes back into the EHR and it's updated several hours after these notes are written on the summary report. You are risking patient records not being updated with the most recent information,” said Assis-Hassid, a Center for Research on Computation and Society postdoctoral fellow at Harvard John A. Paulson School of Engineering and Applied Sciences.

She added, “EHRs don’t support the heart of the medical work, which is when you are interacting with the patient, taking information, thinking about the next steps. The interaction is being documented in handwriting, but that is not very useful.”

"While EHRs have many benefits, the study highlights some critical challenges associated with the technology that echo previous research—especially when it comes to poor EHR usability,” said Raj Ratwani, Ph.D., an EHR safety expert and director of the MedStar Health National Center for Human Factors in Healthcare.

Ratwani was not involved in this study, but in emailed comments to FierceHealthcare, he noted that previous research has shown an association between poor EHR usability and possible harm to patientsincluding children—"as well as what we know anecdotally and from other studies about clinician burnout,” he said.

To address EHR usability challenges in the inpatient setting, the researchers in this latest study recommend three major changes:

  • EHR design changes and interface improvement: Consider different ways of visualizing data to prevent information overload and make the system easy to use in real time in the patient’s room. Better integrate mobile devices as well as complementary health IT tools that support clinicians’ needs and workflow, such as handwriting recognition capabilities on mobile devices.
  • Hospital room adjustments and redesign: Possible approaches include whiteboards that could project EHR data in the room, and positioning the bedside computer so that it does not require the clinician to turn her/his back toward other clinicians in the room and the patient.
  • Care team training programs that consider EHR use during rounds: Programs need to address how the EHR can be better integrated into the workflow and promote EHR use for improving communication and information sharing between care team clinicians.