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Raising Important Issues
The researchers fed scenarios into the EHR systems at 2314 hospitals nationwide. In one scenario, a 52-year-old woman who is taking warfarin once a day to combat deep vein thrombosis (DVT) is admitted to the hospital with pneumonia. Once admitted, the patient receives warfarin 3 times a day with the excessive dosage undetected by the EHR system for 5 days. The patient subsequently suffers a large hemorrhage and dies. “The EHR system does not reliably check for medication errors,” said Dr Classen. “Oncology nurses must be vigilant about making sure that the medication order is safe.”
Neal Patel, MD, MPH, chief informatics officer at Vanderbilt University Medical Center HealthIT in Nashville, Tennessee, said this current investigation has both strengths and weaknesses. “It is interesting, but I don’t think it went into depth.” The conclusions are too over generalized, but the information and the issues raised are important, he explained (email communication, June 2020).
The problem with studying this issue is that not every EHR has the same level of sophistication for clinical decision making. “Different systems have different capabilities. It is like the new car technology. Not all cars have the new features and the elegance,” said Dr Patel.
The scenario of the woman on warfarin admitted to the hospital with pneumonia is common. Warfarin doses must be titrated very carefully, and it is not surprising that the EHR systems fail in this area. “The system rules didn’t catch it as an overdose and that the dose was out of range because the system doesn’t know how to titrate to an individual [patient],” explained Dr Patel.
Common sense would dictate that alerts are put in place for clinicians, however that is not the case in these types of scenarios because of a problem with alert overload. Systems are simply not effective if they are too many alerts, “and these rules can be too tight and you ignore the alert. You get alert fatigue,” noted Dr Patel. This study is helping to draw attention to these failures. It is paramount that all hospitals look at their individual systems and where the weaknesses are to improve outcomes, the researchers concluded.
Reference
Classen DC, Holmgren AJ, Co Z, et al. National trends in the safety performance of electronic health record systems from 2009 to 2018. JAMA Network Open. 2020;3(5):e205547.
