User-unfriendly EHRs pose serious risks to patient safety

Electronic health records that deliver suboptimal user experience are more likely to lead to alert fatigue and less likely to catch errors that could impact hospital safety, University of Utah Health research shows.
By Mike Miliard
11:06 AM

Photo: Helen King/Getty Images

"Hospitals and health systems have spent more than $100 billion on EHRs over the last decade, and most believe that these systems are completely safe and usable but that is not necessarily the case," said Dr. David Classen, a professor of internal medicine at University of Utah Health

Because of this inherent risk in poorly designed electronic health records, all hospitals should "annually perform a safety check on their system to assure it is safe," said Classen, whose EHR research is published in the most recent issue of JAMA Network Open.

Classen worked on the research project with renowned patient safety innovation leader Dr. David Bates, from Brigham and Women's Hospital, as well as scientists at University of California San Diego Health. Researchers at UC San Francisco and KLAS Enterprises also contributed.

He's not one to undersell the scope of the problem – he said the situation is not unlike software glitches that led to two Boeing 737 MAX airplane crashes in 2018 and 2019, with pilots' struggles to make the software work showing more fundamental safety issues.

EHRs' built-in safety mechanisms need to be redesigned, the study suggests.

Classen argues that, just as the Federal Aviation Administration, airline manufacturers and airlines now jointly monitor and improve airline software, something similar needs to happen with EHR vendors, hospitals and clinicians – who should collaborate to optimize EHR software for usability, provider experience and patient safety.

In inpatient settings, EHR alerts, reminders and clinical guidelines pop up to steer clinicians' decision-making, the research notes. But it's long been a known that these notifications are very often more distracting than useful.

Classen, Bates and their researchers studied EHR systems in 112 U.S. hospitals, comparing a survey of user experience for more than 5,000 clinicians with outcomes from  the Leapfrog CPOE Evaluation tool, which examines whether medication orders that could potentially harm a patient are actually detected by alert systems.

They found that user experience strongly correlated with EHR safety: When users rated EHRs poorly, they said the systems were difficult to operate, hard to learn, slow or inefficient. When clinicians experienced those difficulties, the software was less likely to flag drug-drug interactions, drug allergies, duplicate orders, excessive dosing or other harmful medication errors, the research shows.

One explanation might be a lack of quality control, said Classen, with individual hospitals modifying EHRs to meet their own organizational needs without keeping UI and UX top of mind. But without standards for usability, these changes and customizations may be at the expense of safety, he said.

As many as 400,000 people are injured each year from medical errors in the hospital, the research shows – and a big argument for widespread EHR adoption a decade-plus ago was that they could contribute to patient safety.

But past research from Classen and Bates has shown that's not always the case, such as a 2020 report that showed how electronic health records failed to reliably detect medical errors – including dangerous drug interactions – that could cause patient harm.

The safety risk from EHRs to hospital inpatients has long been discussed and debated, with widespread recognition of the need for design optimization and a rethink about the way they lead to less-than-ideal usage patterns.

"Poor usability of EHRs is the number one complaint of doctors, nurses, pharmacists, and most health care professionals," said Classen. "This correlates with poor performance in terms of safety." He added: "Our findings suggest that we need to improve EHR systems to make them both easier to use and safer."

Mike Miliard is executive editor of Healthcare IT News
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Healthcare IT News is a HIMSS publication.

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