Research Finds Only Modest Improvement in EHR Patient Safety

From 2009 to 2018, hospital electronic health records met basic safety standards less than 70% of the time, researchers found.

Much work remains to be done to fully realize patient safety gains from electronic health record (EHR) systems, recent research indicates.

In 1999, the landmark patient safety report To Err Is Human: Building a Safer Health System estimated that 98,000 patients died annually due to medical errors in hospitals. The Institute of Medicine report said that medication errors were the most common preventable harm and called for adoption of EHRs with computerized physician order entry and clinical decision support to improve patient safety.

The recent research, which was published by JAMA Network Open, examines EHR data from 2009 to 2018 collected at more than 2,300 hospitals.

"These findings suggest that despite broad adoption and optimization of EHR systems in hospitals, wide variation in the safety performance of operational EHR systems remains across a large sample of hospitals and EHR vendors. Hospitals using some EHR vendors had significantly higher test scores. Overall, substantial safety risk persists in current hospital EHR systems," the research co-authors wrote.

The researchers assessed computerized physician order entry and clinical decision support data collected through The Leapfrog Group's annual Leapfrog Hospital Survey. The data features information from the survey's computerized physician order entry EHR evaluation tool, which simulates physician medication orders and exposes error rates. The study targeted whether a hospital's computerized physician order entry EHR system produced an alert or stop after a simulated order that could result in an adverse drug event.

The researchers generated several key data points.

• The overall mean total score for computerized physician order entry EHR systems rose from 53.9% in 2009 to 65.6% in 2018. In other words, EHRs met basic safety standards less than 70% of the time.
   
• The mean score for basic clinical decision support rose from 69.8% in 2009 to 85.6% in 2018.
   
• The mean score for advanced clinical decision support rose from 29.6% in 2009 to 46.1% in 2018.
   
• Drug-allergy was the highest performing category, with the mean score rising from 92.9% in 2009 to 98.4% in 2018.
   
• Drug-diagnosis contraindications were the lowest performing category, with the mean score rising from 20.4% in 2009 to 33.2% in 2018.
   
• A hospital's EHR vendor accounted for 9.9% of performance variation.

"We found that overall safety performance increased modestly, while the number of institutions taking the test has increased 10-fold. Improvements in basic clinical decision support were far greater than in advanced clinical decision support, consistent with other studies," the researchers wrote.

Creating safe EHRs

The researchers suggest three ways to improve EHR patient safety performance.

1. Hospitals should conduct computerized physician order entry safety assessments at least annually and after upgrades. "Continuous assessments are also critical to identify unanticipated problems that may occur as systems are updated and customized," the researchers wrote.

2. The results of safety assessments should be shared with EHR vendors to spur development of safer systems.

3. Policy makers could include computerized physician order entry safety assessment scores in publicly reported process quality measures.

EHRs are a pivotal element in hospital patient safety, says Dawn Allbee, MA, executive director of customer engagement at the Oakbrook Terrace, Illinois-based Joint Commission Center for Transforming Healthcare.

"Leaders need to consider that the success of EHRs is an essential tool in their quest for zero harm. This includes optimizing EHRs to help keep patients and organizations safe. Patterns of errors and safety incidents need to be eliminated through the use of an orgnb anization's improvement tools," she recently told HealthLeaders.

At hospitals, a safe EHR is part of a broad landscape of patient safety efforts, Allbee says. "From our perspective, a safe electronic health record is one that is coupled with strong, understood processes for use across the organization. Having an EHR cannot take the place of extensive quality and improvement training that empowers employees as change agents."

The Joint Commission Center for Transforming Healthcare supports the use of the Safety Assurance Factors for EHR Resilience (SAFER) Guides released by the Office of the National Coordinator for Health Information Technology in 2014, she says.

The SAFER Guides feature nine guides organized into three categories.

1. Foundational guides: high priority practices and organizational responsibilities

2. Infrastructure guides: contingency planning, system configuration, and system interfaces

3. Clinical process guides: patient identification, computerized provider order entry with decision support, test results reporting and follow-up, and clinician communication