EMR Safety Warnings at CA Health System Echo Joint Commission's

"Patient safety is impaired by the failure to quickly fix technology when it becomes counterproductive, especially because unsolved problems engender dangerous workarounds."

Those words might have been spoken at last week's Contra Costa County Board of Supervisors meeting in Martinez, CA, where two nurses went public with concerns about the safety of their county health system's July 1 Epic EMR implementation.

In fact, those words were published in 2008 by the Joint Commission. What healthcare leaders have to ask this week is, how seriously have these problems been addressed, since they are still occurring in 2012?

Laura Easley, RN, and Lee Ann Fagen, RN, are nurses at a Contra Costa County hospital clinic at the West County Detention Facility in Richmond, CA. Here's what they had to say last week. 

"We went through the process of meetings where Epic showed health services the workflow they had created," said Laura Easley, RN.  "Numerous times our health team told the Epic group there were many concerns. When we went live with the system, the problems we addressed were even more obvious. Health professionals are being told by non-health professionals how we should conduct our health practice. This cannot be."

"We're unable to document our medication administration correctly," said Lee Ann Fagen, RN. Last week's testimony centered on the possible harm averted when a nurse realized that the Epic system was recommending a possibly fatal dosage of a heart medication.

Contra Costa County Regional Medical Center also operates a 164-bed hospital, and although the testimony last week centered on outlying clinics at three county detention facilities, sources inside the hospital tell me that EMR-related safety concerns are high within the hospital as well.

Because the health system has a policy forbidding unauthorized contact with the media, I cannot identify them.

Communication woes
But both management and workers agree that communication at the hospital about the new EMR has been inadequate. "Epic is a tool, but it does not replace the skill and the knowledge and the experience of our staff, who are in fact, the most powerful components of our safety system," says Anna Roth, RN, CEO of Contra Costa Health Services. "I'm thankful that our staff is diligent."

That diligence comes at a cost, however. I'm told that some documentation that used to take two hours has been known to take four hours now. That translates either as less time spent at the bedside, or as a labor force that is more overworked than before the EMR went live.

Either way, it's bad news.

"The overall safety and effectiveness of technology in health care ultimately depends on its human users, ideally working in close concert with properly designed and installed electronic systems," the Joint Commission wrote in Sentinel Event Alert Number 42, dated December 2008.

Later on there's this: "If not carefully planned and integrated into workflow processes, new technology systems can create new work, complicate workflow, or slow the speed at which clinicians carry out clinical documentation and ordering processes."

So no one can say there hasn't been sufficient, serious warning of the risks of rushing EMRs into use. But with stimulus money for EMR deployment available for a limited time only, the rush to grab that money is clearly at odds with careful planning. This is true to a greater extent now than when the Joint Commission issued its warning.

The Joint Commission report also speaks of the impairment of patient safety by the failure to quickly fix technology. "Unsolved problems engender dangerous workarounds," the 2008 report warns. "Systems not properly integrated are prone to data fragmentation because new data must be entered into more than one system."

System integration issues
At Contra Costa Regional Medical Center, my sources tell me two such major systems are not properly integrated—not an unusual situation for hospitals. The hospital's lab systems are still running software from Meditech, even as the hospital-wide EMR is now Epic's.

If an alarming lab result shows up in Meditech, it will not appear in the patient's Epic-based medical record without extra integration work by vendors and IT staff.  Otherwise, all lab results must be communicated via some other means.

David Runt, CIO of Contra Costa Health Services, acknowledges that the lab runs Meditech while the EMR is Epic's. "We've had some issues with the lab requests flowing over to the laboratory, but those are addressed and fixed as they are raised," Runt says.

The laboratory module is the newest of the Epic suite of products, and has "not a large installed base," Runt says. "We're formerly a Meditech shop, so those Meditech shops that were converting to Epic, many of them have made the decision to stay on the Meditech lab or stay on whatever lab system they were on at the time, so we're not unique in that respect."

Roth says no patients have been seriously adversely affected by anything that can be attributed to the transition to Epic. But my sources say that Epic was concerned enough last week to fly support staff to Contra Costa. I do not, however, have confirmation of this from either Epic or Contra Costa Health Services.

Ulterior union motives?
Because a union raised the red flag in this case, it's reasonable to consider the recent history of northern California nurses' unions. During a nurse lockout at nearly Alta Bates Hospital last September, a patient died while under the care of a temporary nurse hired by the facility during the lockout. Charges and counter-charges flew between labor and management.

It's tempting and perhaps cynical to question the motives of unions that raise safety issues during tense labor negotiations. But since a two-year contract was just signed in June between the California Nurses Association and the Contra Costa system, this newest concern doesn't appear to be a negotiation ploy.

DeAnn McEwen, vice president of National Nurses United, of which CNA is a founding member, argues that management is moving toward an over-reliance on technology at the cost of essential caregivers. "We're not Luddites, we're not saying that we don't see the value of some of it, but when it interferes with or overrides our practice, it puts patients at risk of harm."

McEwen, still nursing during two 12-hour shifts per week at a tertiary care medical center in Los Angeles County, talks at length about healthcare labor issues aggravated by technology. At her own hospital, she says flaws in the Epic implementation have required workarounds for five years, with no end in sight.

"Technology should be assistive to the direct care providers and enhance therapeutic communication," McEwen says. "Cash register-styled electronic documentation systems may serve insurers' and billing department purposes, but overall, they have not been shown to improve patient outcomes or enhance professional communication."

McEwen emphasizes that the problem is bigger than Epic, and so it is. A lot of people like to take and give credit for the rapid automation of healthcare in the U.S. today. Vendors are feted in financial publications. We properly credit the vision of government, provider, and payer leaders in pushing hospital technologies forward.

But in the end, the reason the entire proposition isn't completely running off the rails at this point is the result of the efforts of a whole lot of undertrained, overworked line staff and a whole lot of workarounds.

Let's hope that the efforts now underway at the Office of the National Coordinator for Health Information Technology  to address usability of EMRs leads to some major reforms soon. Meanwhile, the Joint Commission's words of warning continue to echo.