The Centers for Medicare & Medicaid Services (CMS) earlier this year asked for input on how to improve patient safety, specifically when it comes to the usability of electronic health record (EHR) systems or how they are designed and integrated into a hospital’s workflow. In response, stakeholders and advocates weighed in to support policies intended to reduce medical errors through improvements to the implementation and use of EHRs.
A decade ago, enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act started the wide-scale transition away from paper medical records and toward EHRs. Today, nearly all hospitals and most office-based practices use computer systems to house and review patients’ health histories.
Still, despite this progress, research shows that inadequate EHR usability can contribute to patient safety problems. Usability flaws, such as unclear medication lists or default drug measurement settings, can contribute to medical errors. For example, a clinician may inadvertently prescribe the wrong dose of a drug or order the incorrect medication for a patient.
Issues like these can arise from how an EHR system is originally designed, how a health care facility implements or customizes the product, or because of unique workflows within a hospital or clinic. To address site-specific usability issues, health care facilities can take steps to mitigate, monitor, and resolve EHR safety problems. For example, they can test their systems specifically for safety or develop plans to detect risks associated with customizations that can affect high-risk functions, such as the prescribing of medications.
Recognizing this important facet of patient safety and the ways site-specific factors can affect EHR usability, CMS requested information on steps that the agency can take to reduce patient harm. Specifically, CMS suggested that it could encourage steps to promote EHR safety as part of its Promoting Interoperability program, through which the agency offers financial incentives for hospitals to use technology in ways that improve patient care.
In responses to CMS, several organizations lauded the agency for focusing on how EHRs can contribute to patient safety errors and encouraged its leaders to provide incentives for the adoption of best practices, including ones outlined by The Pew Charitable Trusts, the American Medical Association (AMA), and MedStar Health in a report last year.
For example, CMS could set criteria for testing EHRs’ impact on safety, including how frequently such testing should occur and how to conduct assessments of facility-specific customizations that may not have been tested by vendors. Additionally, the agency could encourage facilities to explain the rationale for any customizations and their plans to mitigate risks from more challenging EHR functions, such as medication prescribing.
In their comments, the Drummond Group—an organization that tests whether EHR systems meet federal criteria—and the American College of Emergency Physicians urged CMS to encourage use of safety-focused best practices. Both organizations cited the report from Pew, AMA, and MedStar Health.
CMS also requested specific input on whether to encourage use of the Office of the National Coordinator for Health Information Technology’s SAFER Guides, a series of recommendations that can help health care organizations assess the safety and functions of their EHRs. These guides cover a wide range of topics, from foundational issues like setting organizational responsibilities to complex ones such as how to identify patients or report and follow up on test results.
The Drummond Group, AMA, and American Medical Informatics Association all urged CMS to encourage use of these guides through the Promoting Interoperability program to organizations or providers that attested to using them.
Although CMS has expressed interest in improving safety through this process, other organizations can take steps now to begin reducing EHR usability-associated harm. The Joint Commission, the nonprofit organization that accredits many hospitals for participation in Medicare, could also incorporate EHR safety into its requirements even without action from CMS. For example, The Joint Commission can require as a condition of accreditation that hospitals adopt the same types of best practices—such as development of risk mitigation plans—that CMS could encourage through regulation.
As CMS considers these and other comments, including a response submitted by Pew that makes many similar points, the agency should ensure that future rules recognize the connection between EHR usability and safety, and encourage health care providers to make improving usability a priority so patients can get care that is both high quality and safe.
Ben Moscovitch directs The Pew Charitable Trusts’ health information technology initiative.