Jim Intriglia

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Electronic Health Records Systems Series

Death by 1,000 Clicks Takeaways: A Test and Evaluation Perspective

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On March 18, 2019, an in-depth article, Death by 1,000 Clicks, written by Fred Schulte and Erika Fry for Fortune magazine, was published on the Kaiser Health News (KHN) website.

The article, complete with four video segments, explores U.S. government claims that transitioning American paper-based medical charts into electronic records would make health care better, safer and cheaper.

From my perspective as a Healthcare IT Systems Analyst/Developer who has participated in functional system/software application testing and process improvement initiatives, this article shines a spotlight on key functional areas that need careful testing and evaluation (T&E).

What follows are excerpts from the KHN article organized as functional areas of interest for those engaged in the test and evaluation of EHR platforms.

Clinical Testing and Evaluation

EHR Clinician Alert Overload

"The Joint Commission, which certifies hospitals, has sounded alarms about a number of issues, including false alarms — which account for between 85 and 99 percent of EHR and medical device alerts. From 2014 to 2018, the commission tallied 170 mostly voluntary reports of patient harm related to alarm management and alert fatigue — the phenomenon in which health workers, so overloaded with unnecessary warnings, ignore the occasional meaningful one. Of those 170 incidents, 101 resulted in patient deaths."

"One study by researchers at Oregon Health & Science University estimated that the average clinician working in the intensive care unit may be exposed to up to 7,000 passive alerts per day. Such over-warning can be dangerous."

Medication Ordering and Warnings

"A 2016 study by The Leapfrog Group, a patient-safety watchdog based in Washington, D.C., found that the medication-ordering function of hospital EHRs — a feature required by the government for certification but often configured differently in each system — failed to flag potentially harmful drug orders in 39 percent of cases in a test simulation. In 13 percent of those cases, the mistake could have been fatal."

"Consider the case of Lynne Chauvin, who worked as a medical assistant at Ochsner Health System, in Louisiana. In a still-pending 2015 lawsuit, Chauvin alleges that Epic’s software failed to fire a critical medication warning; Chauvin suffered from conditions that heightened her risk for blood clots, and though that history was documented in her records, she was treated with drugs that restricted blood flow after a heart procedure at the hospital. She developed gangrene, which led to the amputation of her lower legs and forearm."

Order Processing

"In the case of Annette Monachelli, according to court filings, her attending physicians medical Order for a head scan to rule out an aneurysm, never made was transmitted to the lab through the clinic's electronic health records (EHR) system. "

Clinician Warnings and Notifications

"Thirteen-year-old Brooke Dilliplaine, who was severely allergic to dairy, was given a probiotic containing milk. The two doses sent her into “complete respiratory distress” and resulted in a collapsed lung, according to a lawsuit filed by her mother."

"And then there’s the case of Thomas Eric Duncan. The 42-year-old man was sent home in 2014 from a Dallas hospital infected with Ebola virus. Though a nurse had entered in the EHR his recent travel to Liberia, where an Ebola epidemic was then in full swing, the doctor never saw it. Duncan died a week later."

Lab Results

"Rory Staunton, 12, scraped his arm in gym class and then died of sepsis after ER doctors discharged the boy on the basis of lab results in the EHR that weren’t complete."

EHR Usability Testing and Evaluation

Provider EHR Click Fatigue "Cognitive Burden"

"Among the daily frustrations for one emergency room physician in Rhode Island is ordering ibuprofen, a seemingly simple task that now requires many rounds of mouse clicking. Every time she prescribes the basic painkiller for a female patient, whether that patient is 9 or 68 years old, the prescription is blocked by a pop-up alert warning her that it may be dangerous to give the drug to a pregnant woman. The physician, whose institution does not allow her to comment on the systems, must then override the warning with yet more clicks. “That’s just the tiniest tip of the iceberg,” she said".

"The numbing repetition, the box-ticking and the endless searching on pulldown menus are all part of what Ratwani called the “cognitive burden” that’s wearing out today’s physicians and driving increasing numbers into early retirement."

"In recent years, “physician burnout” has skyrocketed to the top of the agenda in medicine. A 2018 Merritt Hawkins survey found a staggering 78 percent of doctors suffered symptoms of burnout, and in January the Harvard School of Public Health and other institutions deemed it a “public health crisis.”

"One of the co-authors of the Harvard study, Ashish Jha, pinned much of the blame on “the growth in poorly designed digital health records … that [have] required that physicians spend more and more time on tasks that don’t directly benefit patients.”

“Everything is so cumbersome,” said Dr. Karla Dick, a family medicine physician in Arlington, Texas. “It’s slow compared to a paper chart. You’re having to click and zoom in and zoom out to look for stuff.” With all the zooming in and out, she explained, it’s easy to end up in the wrong record. “I can’t tell you how many times I’ve had to cancel an order because I was in the wrong chart.”

EHR System, Software & Integration Testing and Evaluation

System and Software Interface Verification

"Interfaces need to be verified to ensure that false-positives are not triggered in partner EHR systems due to interface issues and/or patient data integrity."

Patient Access to their Medical Records

"Competition between healthcare organizations is also a significant factor discouraging sharing of patient data. Healthcare organizations consider patient healthcare records as proprietary. Healthcare EMR vendors do not have incentives to provide interfaces that can make it easier for their customers to change vendors."

Patient Medical Record Errors

"The Pew Charitable Trusts has, for the past few years, run an EHR safety project, taking aim at issues like usability and patient matching — the process of linking the correct medical record to the correct patient — a seemingly basic task at which the systems, even when made by the same EHR vendor, often fail."

"At some institutions, according to Pew, such matching was accurate only 50 percent of the time. Patients have discovered mistakes as well: A January survey by the Kaiser Family Foundation found that 1 in 5 patients spotted an error in their electronic medical records. (Kaiser Health News is an editorially independent program of the foundation.)."

Clinical and Business Application Training

"Training is another area where both vendors and institutions can fall short of needs. healthcare organizations can view training as a loss of revenue as coverage for providers in training needed to be implemented, in addition to the costs associated with the training program itself."