In 2001, the Institute of Medicine Crossing the Quality Chasm report delineated the basic framework for developing structures and processes to support safe, high-quality care in the US. The report included a recommendation to make a “national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education.” The hope was that such a commitment would eliminate most handwritten clinical data by the end of the decade.
Fifteen years later, we clearly have not yet achieved this goal in the United States. Spread of the electronic health record (EHR) has, however, been accelerating over the last five years with government support and incentives. Despite the expectation that EHRs would improve the quality and safety of health care, the unintended consequences of this technology have had a significant impact on communication, data sharing, and care.
What Gets in the Way
There are many challenges that keep the EHR from becoming the quality and patient safety tool we envisioned at the start of the century. These include, but are not limited to:
- Quality measures that are difficult to access electronically;
- Poor interface design that forces providers to spend too much time typing on a keyboard and not enough time paying attention to the patient;
- No national repository for health information technology safety information; and
- Lack of interoperability between multiple systems.
Opportunities for Improvement
The many frustrations that health care staff experience while using the EHR on a daily basis can make it difficult to imagine anything better. The good news? There are many possibilities for improving the EHR, to make it a better tool for helping clinicians improve care.
- Real-time clinical decision support: When alerts and reminders are too numerous or not specific enough, their helpfulness is limited. Worse, they can contribute to “alert fatigue.” In contrast, clinical decision-making tools that utilize the input of both medical devices and clinicians will revolutionize care and improve safety.
- Real-time automated quality metrics: Metrics that are not dependent on human chart abstraction will provide clinicians with the information they need to drive care improvement.
- True interoperability: If different information technology systems and software applications easily communicate and exchange data, this data helps clinicians make better, more informed patient care decisions in a timely manner.
The Impact of Future Health Care Needs on EHRs
In addition to how the EHR can improve current ways we provide care, health information technology (HIT) holds the key to future paradigm shifts in the quality and safety of health care.
- Personalized medicine: Utilizing genomic information can help clinicians provide more individualized care, specific to each patient’s needs.
- True population health management: The ability to collect, analyze, and communicate both medical and social information can help increase understanding of the individual patients and populations we serve. A focus on the subset of patients with chronic disease who utilize the most health care resources will improve care and bring value to patients.
- Patient and family engagement: Providing patients and their families with the information they need to be full partners in care is essential for improved shared decision making.
These lofty goals, however, will not succeed unless there is an integration of HIT and patient safety efforts. Despite efforts to raise awareness, vendors do not focus on ensuring that their products will improve patient safety. They rarely provide expertise on how to improve workflow so organizations can implement the software more effectively.
Reasons for Hope
Despite all of these challenges, there are a number of forces at work that will ultimately drive improvement in HIT and patient safety.
- Most hospitals are becoming part of larger health systems. Although this often means problems with legacy HIT systems, economies of scale enable smaller hospitals to obtain the expertise of the larger system.
- Many physicians are joining health systems as employees or aligning through risk contracts in Independent Practice Associations, providing them with the HIT expertise available in a large health system.
- Health systems are joining Patient Safety Organizations, which provide information on HIT-related safety issues at other organizations.
- The federal government recognized that HIT implementation has far outpaced the ability of organizations to successfully implement EHRs so that they achieve more than Meaningful Use certification. The government has delayed certain benchmarks in order to enable organizations to catch up.
- The rapidly evolving payment system for health care in the US is pushing organizations to recognize the strategic necessity of a robust HIT program.
The EHR will, by the end of the decade, be the primary (and probably only) tool for medical orders, documentation, prescriptions, and the exchange of clinical information. It also will be a critical support for clinical decision making. A comprehensive approach must be developed and implemented so that EHR errors have no impact on patient care. This involves an understanding of how an IT system can impact patient safety at all points in the lifecycle of an EHR, learning from previous errors of EHR implementation, and improving clinical workflows to maximize the capabilities of an EHR.
Mark P. Jarrett, MD, is the Senior Vice President and Chief Quality Officer for Northwell Health (formerly the North Shore–LIJ Health System), and a member of the IHI Leadership Alliance EHR workgroup.
Editor’s Note: Part of this post was adapted from Dr. Jarrett’s thesis for his Master's Degree in Medical Informatics.
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