Specialists: Health IT makes its own particular “Actuality”

Electronic records create a third “reality” in healthcare–one beyond the patient’s physical reality and the clinician’s understanding of the issues and treatment–and yet another way to miscommunicate, according to a new study.What if the physician could take a magic stylus and mark errors and ambiguities for developers to address? That would be an ideal scenario, according to research published online this week in the Journal of the American Medical Informatics Association.The researchers, from Dartmouth College and the University of Pennsylvania, compiled 45 scenarios of miscommunication involving not just EMRs, but also physician order entry systems, pharmacy technology and other systems. They noted that even different clinicians looking at the same screen might develop different ideas about a given situation.

They grouped the problem areas in five categories:

• Information that’s too coarse: Significantly different scenarios are described in the same way. For instance, saying the patient has cancer isn’t helpful to oncologists.

• Information that’s too fine: Very granular categories within ICD-10 might suggest a certainty that does not exist. To select a very specific subcategory of several possible cancers might prevent continued consideration of others.
• Missing reality: Some details are missing. Only lab reports and medications are listed; not symptoms or history.
• Multiplicity: Differing clinicians and staff have differing opinions of reality. Lab results might present others. Including them all can be misleading or distracting.
• Looking glass: When information in an electronic health record creates a different or incorrect reality. Incorrect sensor data, for example, which the clinician would reject, in the EHR becomes a reality that never existed.

Scenarios examined included:

• A pill being ordered for a patient who then vomits it up. Has the patient received the medication? The system would show yes, the medication was administered.
• A doctor ordering medication, but the order not being approved by the pharmacy. In some systems, the order could simultaneously exist and not exist. That could lead another physician to order the medication and the patient to receive a double dose.
• In the United States, weight generally is measured in pounds or kilograms, and medication is ordered using the metric system. Some EHRs, however, do not designate the unit of measurement, so a 5 in weight could be significantly different depending on whether it meant pounds or kilograms. The difference in medication dose could be lethal for newborns.

While many times EHRs do a dramatically better job of reflecting reality than paper records, other times, they fail to reflect the complexity of a situation. That’s why clinicians need the ability to call such problems to the attention of systems developers, the authors said.

“Remediation will require working with all parties and, perhaps more important, empowering clinicians and others to observe problems and to request changes and improvements,” they said, adding, “… Encouraging clinicians to act without subsequent action on the IT side is perhaps worse than doing nothing.”

Health information errors were among the top health technology hazards cited in a report from ECRI Institute, an issue the U.S. Department of Health & Human Services has sought to address with a health IT safety action plan issued in December.

Two workgroups of the American College of Emergency Physicians recently concluded that emergency department EHRs are “particularly error prone.”

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