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Monday Sep 21, 2015

Eye on the Ball: Overreliance on EHRs Can Bring Disaster

My elementary school had computers, and we used them to learn arithmetic. (Anybody remember Number Munchers?) In middle school we were typing our reports on Macs that seemed great at the time but probably would be mocked by today’s teens because of their large floppy disc drives. (OK, you caught me; they were called Apples back then.) By high school we were creating PowerPoint presentations.  

My generation grew up with computer technology, so to me it only seems natural to incorporate that technology into practice. I used paper charts for only one year in residency before that institution adopted electronic health records (EHRs). 

I found paper charts to be cumbersome, inefficient and often illegible and incomplete. However, I would be one of the first to say that our current EHR options, although they continue to improve, are far from perfect. Entering information into these systems can be taxing, and the resulting documentation often has little clinical value. We can all easily read a physical exam in an EHR record, but with overuse of copy and paste and lackadaisical template modification, I’m not sure it’s of any more use than an illegible paper version.  

It's especially troubling to read the recent findings of an expert panel(www.texashealth.org) that concluded that use of a hospital-based EHR was partially to blame for the initial misdiagnosis of Thomas Duncan -- the first person in the United States to be diagnosed with Ebola. Information regarding his travel history was entered into the EHR during triage but was not relayed verbally to the physician.

The patient was diagnosed with sinusitis and abdominal pain and was sent home. He returned to the hospital four days later and was correctly diagnosed but died eight days later.

Apparently, the expert panel was surprised that an alert regarding the patient’s travel history was not programmed into the EHR. Triggering such an alert could have cued care providers to actually review the information that was entered.  

And finally, it was not clear in the EHR whether the physician reviewed the patient’s symptoms. I do some ER work on the side, and although I’m no Dr. Mark Greene (played so aptly by actor Anthony Edwards on the TV series ER), I would find it decidedly difficult to care for a patient in the emergency setting without discussing that patient's symptoms with him or her.  

What troubles me about these findings is not just the weakness in the EHR but also the implied reliance on the system while caring for patients. Although many of us are comfortable with computer technology, perhaps we are all getting a little too comfortable.

While EHRs are becoming more useful in clinical practice, we should not rely on them or expect them to do our work for us. It is our responsibility to review the information contained in the chart -- be it paper or pixels -- whether or not an alert is triggered.

We also must keep in mind that just because something is in the EHR does not make it gospel. I was reviewing the chart of a female patient that noted a prostatectomy under her surgical history. We must always confirm information with the patient and take a history for ourselves. Although the headline of a recent news story(www.beckershospitalreview.com) on the report would have us believe that somehow the EHR was to blame, this is akin to watching a major league baseball player strike out and then look incredulously at his bat.

The types of mishaps that occurred in this case have been around for ages: lack of communication between health care professionals and incomplete history review. The twist is that these errors occurred in this day and age because we have come to expect the EHR to fill in the blanks for us. Although the EHR is a powerful tool to aid in patient care, it is just that, a tool. And like most tools, without a skilled operator who knows the tool's capabilities and limitations the end result can be pretty shabby.

Peter Rippey, M.D., enjoys outpatient family and sports medicine practice in a hospital-owned clinic in South Carolina.

Posted at 02:20PM Sep 21, 2015 by Peter Rippey, M.D.

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