In healthcare, we spend plenty of time talking about patient safety, and rightfully so. But I’ve noticed that oftentimes it is the clinician who walks away from an experience with an EHR feeling “unsafe.”
I was working in the ER shortly after our go-live with Epic. In typical emergency-room fashion, we were seeing a lot of patients. It was a busy place, and we covered various degrees of illness. One particular patient had what’s called an unstable angina (USA), which is essentially an almost heart attack that comes and goes.
The offending clot teeters on the edge of causing blockage. One of the initial treatments for USA is a medicine called Heparin. I had several less critically ill patients in the ER at the same time, including one with an ankle fracture.
While trying to provide care in this busy environment, I had several tabs open in the EHR — each with a different patient chart. I accidentally ordered Heparin, a very powerful blood-thinning medicine, for my ankle-fracture patient. Fifteen minutes later, the nurse approached me and half-jokingly asked, “Did you really mean to order Heparin on your ankle fracture? Is this a new treatment that I am not aware of?”
I was floored. I went back to the EHR and pondered, “How could I have done that?” Obviously, I canceled the Heparin and re-ordered it for my unstable angina patient, but the ill feeling in my stomach lingered.
It’s important to note that, at this point in our digital journey, nobody in our ED was more familiar with the use of the EHR than me. Spending months building out our instance of the EHR brought me a level of familiarity that was both hard-earned and authentic.
Yet despite this level of engagement, I efficiently ordered a potentially dangerous medication without giving it a second thought. If someone with my level of exposure to the EHR can make this type of mistake, is it really any surprise that many clinicians don’t feel safe trusting their actions within the EHR?
This speaks to the criticality of great human relationships. Not only did that nurse recognize my error and feel confident enough in her role to trust her instincts, but she felt comfortable coming up to me and saying, “Get it straight, Lee.”
At the end of the day, that relationship saved my neck, saved the patient, and got our ED care back on track. That wasn’t the first time — and I doubt it will be the last — that a competent and engaged nurse saved the day.
For the case I described, I own my part in ordering the wrong medicine for the wrong patient. However, current EHR systems don’t do a great job at pointing out this sort of error before it’s too late. Clinical decision support (CDS) has been implemented by nearly every EHR vendor, but for those of us who use these systems, CDS remains rudimentary at best. It generally over-fires on most clinically unimportant scenarios and under-fires where you really need it. The result is alert fatigue — the desensitization of clinicians to safety alerts. Because of this, when CDS systems do fire, clinicians frequently ignore them or “click out” of alerts without fully digesting what message they intended to convey.
For dedicated physicians, all of this contributes to the chaos of the experience. Remember, they spent over 15 years mastering patient care around a specific domain to become experts in their field.
Throughout this span, physicians learn to zero in on three elements with each patient:
- Building a relationship with the patient;
- Diagnosing the problem;
- Treating the patient with medicine and/or surgery to effect a cure.
Let’s consider a typical ambulatory encounter. From the vast array of maladies that a patient’s symptoms may represent, the clinicians first need to narrow the options down to a small differential diagnosis; without this, they can’t effectively treat the patient. In a typical situation, clinicians are trying to both build that relationship and simultaneously use most of their “cognitive RAM” to think through the diagnostic process.
In the midst of this interpersonal patient-care setting, clinicians sit down in front of a computer packed with icons, navigators, and wording which, in aggregate, look like the cockpit of a commercial airline.
In the presence of the patient, clinicians then find themselves digging for the proverbial needle in the haystack, and they quickly recognize that they are at risk of appearing incompetent in front of their patient. Thus, the clinicians (a) don’t find what they need, (b) are embarrassed by their perceived incompetence, and (c) project an image which is antithetical to the confidence they desire. Is it any wonder that physicians frequently verbalize that they want to punch the screen? To top it off, physicians are rightly concerned that the EHR system could lead to any number of medical errors, either errors of commission or omission.
An example of an error of commission would be what I described in the aforementioned case — ordering the wrong medicine for the wrong patient. An EHR error of omission can be just as dangerous.
These may come in the form of a missed critical lab value buried deep within the chart, or a note from another physician who saw the patient and observed something critical but whose insights are lost in the narrative of a bloated copy-paste note. For many clinicians, it feels like a minefield. Focus too much on avoiding errors of commission, and you’re liable to step on an explosive omitted detail.
This piece is the first in a two-part series written for KLAS by Lee Milligan, MD, CMIO at Asante, a multi-hospital system serving patients in nine counties throughout Southern Oregon and Northern California. The next segment will discuss both immediate and long-term solutions that can help improve EHR usability and put clinicians at ease.