New EHRs Perform Better, But Transition Pains DoctorsNew EHRs Perform Better, But Transition Pains Doctors

12 Advances In Medical Robotics

For many physicians looking to apply for federal incentive payments when they adopt electronic health records (EHRs), switching to newer EHRs will be necessary as they update their health information technology to demonstrate meaningful use. However, while newer systems come with improved features, the transition between systems poses significant problems, a study from Weill Cornell Medical College shows.

The study, which was supported by funding from the Agency for Healthcare Research and Quality, was conducted by a team of physician-scientists from Weill Cornell Medical College, who monitored the prescription errors of 19 physicians in an adult ambulatory clinic before the switch from an older EHR to a newer system, then again 12 weeks after the switch and once again a year later.

Results of the study, which was conducted to gauge the reaction of physicians on the transition to newer EHRs and to track prescription errors, were published recently in the Journal of General Internal Medicine.

The study noted that while there were significant efforts made to facilitate a smooth transition, 40% of doctors weren't satisfied with the implementation of the new system, and only one-third thought it was safer than the old one. In particular, 60% reported that the alerts weren't useful, and two-thirds indicated that the new system slowed down drug orders and refills.

Dr. Rainu Kaushal, chief of the Division of Quality and Medical Informatics in the Departments of Pediatrics and Public Health at Weill Cornell Medical College, said the study highlights the complexities that can arise when humans interact with new technology that will change their workflow.

"I think it's a little more complex than just a new generation of technology, new forms of decision support, and the implementation of that decision support," Kaushal said in an interview. "Every EHR has complexities in terms of who is using it, how they are using it, whether or not certain pieces of decision support are turned on or turned off and so on … and all of that can raise safety risks or introduce safety protection, and that's why studying this is so important."

Kaushal, who said she's a big supporter of EHRs and appreciates the advancements that digitized medical records can made to improve the quality of healthcare delivery and outcomes, also said that many physicians are not convinced that using these systems in their healthcare setting can make a material difference that will improve their daily tasks or their ability to deliver care.

"What we are asking physicians to do is to change the way in which they conduct their day to day activities without clearly having proof that that a given system in their clinical setting with their use is going to improve the quality, safety and efficiency of care," Kaushal said. "I think that as the literature accumulates showing that these systems do improve the quality, safety, and efficiency of care and, perhaps even more important, as individual physicians begin to come to that conclusion, that will be outstanding and I think that's when the level of resistance to adopting newer EHRs will go down."

The study's lead author, Dr. Erika Abramson, assistant professor of pediatrics and of public health at Weill Cornell Medical College, said doctors should receive individualized instruction and close follow-up attention during the transition from older to newer EHR systems.

"Providers have substantial requirements for training and support. We need to make sure that the systems are easy for providers to use and don't cause workflow problems," Abramson said.

Despite clinicians' reservations about using EHRs, the researchers found that the new system can reduce prescription errors. They analyzed nearly 4,000 prescriptions for more than 2,000 patients and noted mistakes in abbreviations, usage directions, dosage, the quantity of medications to be dispensed, and more.

According to the researchers, the new electronic system had several positive attributes, including providing extra guidance for prescribing to improve safety, such as alerts notifying providers about inappropriate abbreviations that can result in patient harm, as well as checks for drug-allergy interactions, drug-drug interactions, and duplicate drugs.

The researchers found that by using the newer EHR, the rate of prescription errors dropped by two-thirds, from about 36% to about 12% one year later. They also found that the rate of improper abbreviations, such as the outmoded "QD" instead of "once daily," fell by three-quarters, from about 24% to about 6% one year later; nonetheless, these remained the most common type of mistake at all three time periods. Meanwhile, the rate of non-abbreviation errors rose from about 9% to about 18% 12 weeks later, but it declined to the baseline level after one year.

To smooth the transition and further reduce prescription errors, the researchers suggest that the systems should be designed to detect and fix the most typical mistakes, as well as focus on the most clinically important mistakes so that providers don't begin to ignore alerts whenever they appear. Additionally, investigators should periodically reassess the effectiveness of such refinements.

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