Report finds user error and software quirks responsible for challenging EHR implementation

Most health care professionals agree that electronic health records will eventually save them time and money, but in the short term, EHRs are proving cumbersome at best. A recent report from the Institute of Medicine, which was published in the Journal of Medical Information Association, explores some of the most common concerns healthcare providers have observed in their efforts to change from paper to electronic medical records. They found that there is not a single cause of the difficulty and strife behind EHR implementation. Rather, it is caused by a slew of reasons, not all of which are directly related to one another.

The study drew its data from 100 consecutive, unique, closed investigations over a period of nearly four years from August 2009 to May 2013, which involved 344 reported incidents. Out of those 344 incidents, 74 involved either unsafe hardware or software, and 25 involved unsafe use of EHR technology.

Many of these instances were complicated by a combination of non-technical elements, such as workflow, policies and user error, and technical elements such as software and hardware interfacing. Almost 94 percent of the safety concerns highlighted by this study were directly related to EHR data-display features, software upgrades or modifications, data transmission between different parts of the EHR or hidden dependencies within the software.

Problems displaying and interpreting data
One commonly advertised feature of EHR software is its ability to immediately alert medical personnel of patient health history as it relates to treatment. Specifically, EHRs are supposed to inform doctors and nurses of past treatments, allergies and drug interactions. However, because of the layouts of some EHRs as well as problems with data entry, some of this information can get lost or swallowed up by the rest of the content of the EHR.

The study found that in some cases, data fields were not large enough, and information that was entered into the EHR would not be visible past a certain point. Other times, there was so much text on a patient's record that the attending physician could not quickly separate relevant information from less important text. All told, problems stemming from the displaying and interpretation of data accounted for 36 incidents.

Software updates, patches and new content implementation
Although updates, patches and new content are meant to improve EHR performance, they can sometimes cause more problems than they fix. In one case, which was highlighted by the report, a modification to a .config file in one office's EHR software resulted in an inability to communicate with a printer that was used to label lab specimens. The lab personnel were unfamiliar with this particular printer, and, as such, it took a very long time to identify the problem.

This incident, like many of the others, was not caused by a single culprit. Rather, it was the result of a combination of EHR coding issues and human error. Nonetheless, issues stemming from software updates, patches and new content implementation accounted for 24 of the incidents studied by the Institute of Medicine.

There are many challenges presented by the change from physical records to digital, but one of the more common is in mixing up files. Unlike paper files, which have more visual cues to distinguish between them, digital files are uniformly similar in appearance. As a result, many doctors and nurses have been experiencing difficulties stemming from entering the wrong information into the wrong files. This is largely a user error, but software solutions could be developed to address the visual similarity of patient files.

Hidden dependencies
Similar to those errors stemming from software updates, hidden dependencies are lines of code in a piece of software that are reliant on other, seemingly unrelated sections of the code. This can be confusing since two features, like patient intake and interoffice data transfer, may seem like two separate entities, but it is entirely possible that one might not work without the other.

Therefore, if a user ignores an update or decides that one of those features can be neglected or disabled, the other one may not function properly. Like almost all of the other instances, those stemming from hidden dependencies are equally related to human error and software problems.

Possible solutions
It might be easy to place the bulk of the blame on EHR developers, but that ignores a large part of the problem. Doctors and nurses who choose to adopt EHR software need to learn how to use it. Basic training is necessary for any new software, but EHRs are special. These health records contain information that is vital to the survival and effective treatment of patients. 

Providers need more than basic training with their software systems. They need to devote time to practicing with their software. Moreover, if issues like hidden dependencies and problems stemming from updates or patches are to be resolved, then the people using the software and experiencing these issues need to report their observations to the software developer.