Electronic health records and patient safety: should we be discouraged?

To cite: Payne TH. BMJ Qual Saf 2015;24:239–240. For decades we have looked hopefully to electronic health records (EHRs) to aid efforts to make healthcare safer. Early research gave basis to this hope: automated alerts and reminders were shown to improve preventive and chronic illness care, electronic records could be better organised and more easily delivered where needed, automated computerised decision support (CDS) can help make diagnoses and plan treatments, and computerised practitioner order entry (CPOE) was shown to reduce risk for serious adverse drug events. Since 2009, the USA has joined other countries in broadly adopting EHRs. 8 Through the meaningful use programme, and other efforts, use of CPOE has also grown tremendously. This transition has not been easy and has uncovered weaknesses in EHRs, including problems with usability, interruption of workflow, and concerns for altered interaction with patients. We are discovering that the transition from paper to electronic records is a long, difficult journey that is far from complete. There is an enormous need for improvements in EHRs, and efforts to do so are reinvigorated by evidence that we have made not made as much progress in patient safety in the last decade as we had hoped. The difficult question is how to make these improvements. In part, the answer is that we get better by gathering data and learning from them. In this issue, the paper by Schiff et al contributes to that effort. They have carefully studied and categorised a sample of over 10 000 errors in which CPOE played a role from among 1 million medication errors reported in the United States Pharmacopeia MEDMARX database. They meticulously analysed and categorised these CPOE-related errors, and then created scenarios to test whether similar errors could occur when entering orders into the current generation of CPOE systems. They found that most of these erroneous orders could be placed, some very easily, into modern CPOE systems. For example, one could prescribe pioglitazone, a member of a class of medications for diabetes known to cause fluid retention and thus potentially exacerbate heart failure, for patients with heart failure, though one would hope such an order would at least be flagged for review. The authors are to be commended for this effort, especially since they are the first to take advantage of this CPOE experience collected in MEDMARX. We should not overlook that selfreporting systems such as MEDMARX usually contain a small biased subset of the full population of problems. Those reporting errors were usually not those entering orders, so the database contains mostly second-hand reports, some lacking sufficient detail. Even after the enormous effort this study represents, we have only a partial view into CPOE problems and how they might be solved. In a medium sized hospital over 10 000 orders will be entered in a day, and there are over 5000 hospitals in the USA, so there is ample experience to tap. It will surprise some—particularly those who do not use these systems—that many of these errors are not caught by CPOE systems in use today. How can it possibly be that current CPOE systems don’t catch seemingly simple problems in orders, problems that were reported over a decade ago? The short answer is that erroneous orders should be caught, and risk for harm avoided. However as with many short answers, there are more complex sides to this question. EHRs are extremely complex, and problems with them span all EHR functionality such as displaying results, allowing notes to be entered quickly and accurately, reconciling medications, and ordering many services other than medications, such as imaging and laboratory tests. EHR usability must be improved, they must better fit workflow, and be faster to use. So there is lots to improve, and these improvements are EDITORIAL