The current issue of JAMA has a very interesting commentary by Drs. Singh and Graber highlighting the complex challenges of improving safety concerns in practice with a focus on reducing diagnostic errors (missed, delayed, or incorrect diagnosis). The authors point out that while EHRs can facilitate the transmission of clinical information, there is no guarantee that clinicians will review and respond appropriately. For a variety of reasons, diagnostic information is still missed even when clearly documented in EHRs. The authors point out that one likely contributing factor is the sheer volume of information flowing through EHRs (lab results, alerts, reminders) as well as the format in which these data are presented to the clinical team.
A key quote from the article reads, “Electronic health records must be optimized to provide the right information rather than all the information.”
Here are some additional thoughts based on points made by Singh and Graber:
1) Using teams to support information gathering and review can be helpful but only if the appropriate delegation of tasks is accomplished. Absent an effective team with well-defined tasks and responsibilities, there is the potential that dividing work responsibilities can actually increase safety concerns because of faulty hand-offs and poor transitions of information across the team.
2) Whereas EHRs will help transmit information, there may still be communication breakdowns. For example, how many times have you sent an email, text message or left a voice mail for a friend/family member who didn’t respond or act upon the content of your communication? Multiply those exchanges and even a few missed clinical indicators in the service of patients could result in unintended consequences. Therefore, a practice should establish policies pertaining to the review of incoming data and use the EHR system to support tracking of correspondence, consultations, labs/tests ordered, and results.
3) Patients and their families, if supported and encouraged by a practice, can be very effective as partners in helping to avoid and/or detect diagnostic errors. Clinical summaries provided to patients, access to test results, automatically generated reminders, and personal health records can help patients become active members of the clinical team and more involved in their own care.
It’s important to recognize that identifying the EHR that best matches your practice needs will not overcome a lack of focus on process improvement or poor preparation of the practice staff. Identifying key clinical quality goals, office culture challenges, and operational impediments to optimizing the technology purchased are critical to the success of every EHR implementation.
One quick way to gain a sense of your practice’s ability to negotiate the transition to EHRs is to work through the AmericanEHR Readiness Test. It may be interesting to have members of your team answer the questions independently and then compare responses/scores. You might be surprised about the differences of opinion. Once the practice has identified potential areas of weakness to address, develop a strategy with the members of the practice team to overcome them.
There may be a rare practice that can successfully implement and optimize certified EHR technology without taking some of the steps noted above. However, success will likely be correlated with those practices that take the time to do an honest practice assessment, develop a logical, achievable plan for change, and continuously monitor operations and quality indicators to determine if goals are achieved. Among those goals should certainly be the reduction of diagnostic errors given the significant opportunities current research tells us we have for improvement.
What concerns do you have about practice culture, office work flow, and the use of technology to support clinical quality improvement and enhanced safety?
This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.