Source: Medscape Medical News

A commentary published in the September 9 issue of JAMA offers 8 recommendations to ensure that electronic health records (EHRs) are used safely and effectively by key stakeholders who are either involved in their use now or who will be involved in the near future, in accordance with a federal initiative to expand EHR use.

"With high-quality, well-designed, and carefully implemented systems, highly-reliable, safe health care will be achieved," commentary author Dean Sittig, PhD, an associate professor at the University of Texas School of Health Information Sciences at Houston and member of the University of Texas–Memorial Hermann Center for Healthcare Quality and Safety, said in a news release. "The American Recovery and Reinvestment Act stipulates that clinicians and healthcare organizations can receive incentive payments for 'meaningful use' of EHRs. Depending on the definition and timeline for 'meaningful use,' this legislation could result in a rush to implement sub-optimal systems."

Dr. Dean Sittig

The American Recovery and Reinvestment Act of 2009 has allocated about $20 billion in incentives for "meaningful" use of EHRs by individuals and organizations, starting in 2010. At present, only 4% of physicians in the outpatient setting and 1.5% of US hospitals have a comprehensive EHR system, according to findings of previous studies.

However, if the Computerized Patient Record System developed by the Department of Veterans Affairs (VA) were included in the EHR-use study, the percentage of US hospitals with a comprehensive EHR system would nearly double to 2.9%. This EHR system facilitates sending reminders for preventive healthcare, electronic order entry, laboratory test results display, consultation requests, pathology and imaging studies, and many other facets of patient care.

"This framework can help make sure that EHRs are used safely and effectively as doctors continue to adopt them," said coauthor Hardeep Singh, MD, MPH, an assistant professor of medicine and health services research at the VA Health Services Research and Development Center of Excellence and Baylor in Houston. "While using EHRs, we not only have to consider issues related to technology but also issues related to people who use them, how they interact with technology, and how the EHR fits with the work flow of the clinic or organization that adopts it."

Dr. Hardeep Singh

Dr. Sittig and Dr. Singh advocate 8 essential recommendations, based on a systems engineering model for patient safety, to realize the full potential of EHRs. Ideally, an EHR system should lead to lower costs, less duplication, and greater quality. Their specific recommendations are as follows:

1. The proper hardware and software must be in place and readily available to the clinician and healthcare organization before the EHR system is implemented. Disruption or slowing of clinician work flow by hardware or software problems could put patient safety at risk. The Veterans Information Systems and Technology Architecture and other free EHR software programs are available. However, safe and effective use of an EHR system mandates attention to all of the other 7 essentials in the framework.
2. For effective information sharing, content must be reported using standardized vocabulary to describe clinical findings, as requested by the federal government as a prerequisite to implementing advanced clinical decision support.
3. The user interface should allow easy access to and entering of clinical information, presenting all pertinent data in a manner that facilitates rapid recognition of and response to clinical problems.
4. Appropriate, qualified personnel, including trained and knowledgeable software designers, developers, trainers, and implementation and maintenance staff, must be hired by healthcare organizations to ensure safe implementation of EHR systems. The requisite knowledge and skills for many of these positions have been identified by the American Medical Informatics Association, and the School of Health Information Sciences at Houston now offers educational programs and degrees relevant to these positions.
5. Work flow and communication should be ensured by thoroughly testing the EHR system before implementation within the clinic or hospital where it will be used, allowing any problems to be addressed and corrected before the system is in place.
6. Needed organizational characteristics include an ongoing surveillance system to report errors and identify obstacles to appropriate care, thereby facilitating innovation, exploration, and continual improvement. The authors cite the VA EHR system as a model of many of these organizational features.
7. To protect patient safety and privacy, state and federal rules and regulations must be followed.
8. Even after initial implementation and use, ongoing monitoring and oversight are vitally important to the success of the switch from paper-based patient records to electronic records.

"These issues are essential to maximize patient care benefits and minimize unintended errors from technology," Dr. Singh said.

"Success in the next 10 years will require a coordinated multidisciplinary research and development effort, much like the formation of National Aeronautics and Space Administration following President Kennedy's promise of a moon landing, to bring the best scientists, engineers, and clinicians together to address the problems and challenges in ensuring safe and effective use of EHRs," the commentary authors conclude. "Efforts must move beyond the lone informatics researcher in an isolated laboratory if the complex interaction of organizational, technical, and cognitive factors that affect the safety of EHRs are to be understood and addressed and without this understanding, any solutions are certain to be far from optimal. Without high-quality, well designed, and carefully implemented EHRs, highly reliable, safe health care may never be achieved."

The commentary authors received support from the National Library of Medicine, the VA National Center of Patient Safety, the Houston VA Health Services Research and Development Center of Excellence, and the Agency for Health Care Research and Quality. The authors have disclosed no relevant financial relationships.