EHR shortcomings harm care coordination, risk patient safety, study finds

By | March 1, 2019

Dive Brief:

  • Shortcomings in EHR design and functionality, workarounds and care team communication issues are putting patient care and safety at risk, according to a new PLOS One report.
  • Rather than improve communications within care teams, EHRs often have the opposite effect, especially while clinicians are in the patient’s room.
  • The researchers observed care teams during morning rounds at a major teaching hospital in New England to see how EHRs support workflow. They also conducted interviews and did an electronic survey of inpatient clinicians. What they found was a wide variance in what EHRs are used and by whom, and a “pervasive use of workarounds at critical points of care.”

Dive Insight:

EHRs have long been blamed for adding to clinician stress and burnout, but this study shows how their use can undermine patient care and weaken care team communications. It’s possible standardization could help, but that’s not a near-term solution. To keep patients safe and providers happy, hospitals need to understand where EHRs support care team workflow and where they don’t, and take steps to close the gap.

Design and usability led concerns around EHRs, with clinicians citing frustration over efforts to access information. “It’s not really presented in a way that’s useful,” one clinician told the researchers. “I always have to click twenty different places to access something. To look at results I can do it in twenty different ways.”

Asked whether EHRs improve efficiency during rounds, attending clinicians were split, with half saying it is useful only some of the time and half reporting it useful most of the time.

The study found a high level of variance in the type of clinician using an EHR on morning rounds, the way it was used and the type of device. Clinicians routinely used EHRs before entering patient rooms, but only sometimes inside rooms. After exiting patient rooms, 40.6% of clinicians and 50% of residents reported sometimes using the EHR, compared with 50% of interns and 53.8% of physician assistants who said they always use the EHR at that point.

Type of device also varied. Few clinicians reported using iPads rarely during rounds and only sometimes using smartphones or bedside computers. Nearly seven in 10 said they sometimes use computers on wheels. The most popular data entry point was the nurses’ station desktop computer.

The study also showed extensive use of workarounds — nonstandard procedures often used to make up for gaps in system or workflow design. Workarounds included handwritten notes, emails, verbal discussions and patient summary reports.

Such deviations and shortcuts “pose a threat to quality of care and patient safety, as they could potentially cause overlooking important information and result in lack of synchronization between care team members,” the researchers write.

As to sharing EHR information, clinicians rarely communicated while in the patient’s room and only sometimes before going in. Issues inside the room include location of the computer that prevented face-to-face team interaction, difficulty simultaneously focusing on verbal and on-screen communication and non-user friendly presentation of information on EHRs.

Increasing the benefit of EHRs in clinician workflows will require improvements in system designs and functionalities, as well as care team training and changes in hospital room settings, according to the study.

“It would be beneficial to 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,” the researchers write. Hospitals could also do more to integrate mobile devices and complementary health IT tools that support clinicians’ needs and workflow.

Hospitals should explore better ways of sharing EHR information, such as whiteboards to project data inside patient rooms and integrating EHRs into workflows in ways that don’t impede team communication, they add.

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