Thursday, October 11, 2012

Improving Patient Safety Through Electronic Health Record Simulation

Most tools used in medicine require knowledge and skills of both those who develop them and use them. Even tools that are themselves innocuous can lead to patient harm. For example, while it is difficult to directly harm a patient with a stethoscope, patients can be harmed when improper use of the stethoscope leads to them having tests and/or treatments they do not need (or not having tests and treatments they do need). More directly harmful interventions, such as invasive tests and treatments, can harm patients through their use as well.

To this end, health information technology (HIT) can harm patients. The direct harm from computer use in the care of patients is minimal, but the indirect harm can potentially be extraordinary. HIT usage can, for example, store results in an electronic health record (EHR) incompletely or incorrectly. Clinical decision support may lead clinician astray or may distract them with unnecessary excessive information. Medical imaging may improperly render findings. Search engines may lead clinicians or patients to incorrect information. The informatics professionals who oversee implementation of HIT may not follow best practices to maximize successful use and minimize negative consequences. All of these harms and more were well-documented in the Institute of Medicine (IOM) report published last year on HIT and patient safety [1].

One aspect of HIT safety was brought to our attention when a critical care physician at our medical center, Dr. Jeffery Gold, noted that clinical trainees were increasingly not seeing the big picture of a patient's care due to information being "hidden in plain sight," i.e., behind a myriad of computer screens and not easily aggregated into a single picture. This is especially problematic where he works, in the intensive care unit (ICU), where the generation of data is vast, i.e., found to average about 1300 data points per 24 hours [2]. This led us to perform an experiment where physicians in training were provided a sample case and asked to review an ICU case for sign-out to another physician [3]. Our results found that for 14 clinical issues, only an average of 41% of issues (range 16-68% for individual issues) were uncovered.

While this rate of error is alarmingly high, it must be remembered that the physicians reviewing the case were new to it, i.e., not taking direct care of the patient. It is also important to remember that paper-based information management in the ICU has always had its problems as well. Nonetheless, there clearly needs to be improvement both in the presentation of information as well as the training of users to access it.

As we were completing this work, a new round of funding was announced for a grant program, Improving Patient Safety Through Simulation Research, by the Agency for Healthcare Research and Quality (AHRQ). I am pleased to report that we have been awarded a three-year, $1 million grant to pursue this work. Dr. Gold is Principal Investigator of the project and several faculty in our informatics program, including myself, are Co-Investigators. Our efforts will focus on continuing the development of the simulation through development of new cases, aiming to improve both the user interface as well as user training, and disseminating our results. Of course, we are not the only research group evaluating improved methods to find and use data in the EHR, our simulation approach is novel and will hopefully add additional insights to improving the use of HIT in the clinical setting.

1. Anonymous (2012). Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC. National Academies Press.
2. Manor-Shulman, O., Beyene, J., et al. (2008). Quantifying the volume of documented clinical information in critical illness. Journal of Critical Care, 23: 245-250.
3. Steiger, D., March, C., et al. (2012). Use of simulation to assess and improve electronic medical record usage. American Journal of Respiratory and Critical Care Medicine, 185: A2890.

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