Electronic Health Records and Patient Safety

Summary

Background: The role of electronic health records (EHR) in enhancing patient safety, while substantiated in many studies, is still debated.

Objective: This paper examines early EHR adopters in primary care to understand the extent to which EHR implementation is associated with the workflows, policies and practices that promote patient safety, as compared to practices with paper records. Early adoption is defined as those who were using EHR prior to implementation of the Meaningful Use program.

Methods: We utilized the Physician Practice Patient Safety Assessment (PPPSA) to compare primary care practices with fully implemented EHR to those utilizing paper records. The PPPSA measures the extent of adoption of patient safety practices in the domains: medication management, handoffs and transition, personnel qualifications and competencies, practice management and culture, and patient communication.

Results: Data from 209 primary care practices responding between 2006–2010 were included in the analysis: 117 practices used paper medical records and 92 used an EHR. Results showed that, within all domains, EHR settings showed significantly higher rates of having workflows, policies and practices that promote patient safety than paper record settings. While these results were expected in the area of medication management, EHR use was also associated with adoption of patient safety practices in areas in which the researchers had no a priori expectations of association.

Conclusions: Sociotechnical models of EHR use point to complex interactions between technology and other aspects of the environment related to human resources, workflow, policy, culture, among others. This study identifies that among primary care practices in the national PPPSA database, having an EHR was strongly empirically associated with the workflow, policy, communication and cultural practices recommended for safe patient care in ambulatory settings.

Citation: Tanner C, Gans D, White J, Nath R, Pohl J. Electronic health records and patient safety – co-occurrence of early EHR implementation with patient safety practices in primary care settings. Appl Clin Inf 2015; 6: 136–147

http://dx.doi.org/10.4338/ACI-2014-11-RA-0099

Keywords

Electronic health records and systems - safety culture - organizational change management - work-flows and human interactions - sociotechnical aspects of information technology

• References

• 1 Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health system. Washington, DC: National Academy Press; 1999
• 2 Harrison MI, Koppel R, Bar-Lev S. Unintended Consequences of Information Technologies in Health Care—An Interactive Sociotechnical Analysis. J Am Med Inform Assoc 2007; 14 (05) 542-549. doi: 10.1197/jamia. M2384
• 3 Sittig DF, Singh H. A New Socio-technical Model for Studying Health Information Technology in Complex Adaptive Healthcare Systems. Qual Saf Health Care 2010; 19 (Suppl. 03) i68-i74.
• 4 Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Toon C, Brennan TA, Studdert DM. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med 2006; 145 (07) 488-496.
• 5 Lapetina EM, Armstrong EM. Preventing errors in the outpatient setting: a tale of three states. Health Aff (Millwood). 2002; 21 (04) 26-39.
• 6 Gandhi TK, Weingart SN, Seger AC, Borus J, Burdick E, Poon EG, Leape LL, Bates DW. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Intern Med 2005; 20 (09) 837-841.
• 7 Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR. Ambulatory patient safety. What we know and need to know. J Ambul Care Manage 2003; 26 (01) 63-82.
• 8 Sokol PE, Neerukonda KV. Safety Risks in the ambulatory setting. J Healthc Risk Manag 2013; 32 (03) 21-25.
• 9 Lorincz CY, Drazen E, Sokol PE, Neerukonda KV, Metzger J, Toepp MC, Maul L, Classen DC, Wynia MK. Research in Ambulatory Patient Safety 2000–2010: A 10-Year Review. Chicago:: American Medical Association; 2011: 194 p. (Note: Report is no longer available online but available directly from AMA)
• 10 Thomsen LA, Winterstein AG, Sondergaard B, Haugbolle LS, Melander A. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Ann Pharmacother 2007; 41 (09) 1411-1426. Epub 2007 Jul 31.
• 11 Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, Taylor R. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff 2005; 24 (05) 1103-1117.
• 12 Committee on Patient Safety and Health Information Technology; Institute of Medicine.. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington (DC): National Academies Press (US); Nov 2011. http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx. Accessed 9/22/14.
• 13 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005; 83 (03) 457-502.
• 14 Donaldson M, Yordy K, Lohr K, Vanselow N. Editors. Primary Care: American’s Health in a New Era. Institute of Medicine Committee on the Future of Primary Care 1996.
• 15 Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. „I wish I had seen this test result earlier!“: Dissatisfaction with test result management systems in primary care. Arch Intern Med 2004; 164 (20) 2223-2228.
• 16 Wahls T. Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. J Ambul Care Manage 2007; 30 (04) 338-343.
• 17 Forjuoh SN, Giardina TD, Meyer AN, Reis MD, Singh H, Thomas EJ. Types and Origins of Diagnostic Errors in Primary Care Settings. JAMA Intern Med 2013; 173 (06) 418-425.
• 18 Office of the National Coordinator for Health IT. SAFER (Safety Assurance Factors for EHR Resilience) Guides Jan 2014. http://www.healthit.gov/safer/ . Accessed 9/22/14
• 19 Pohl JM, Nath R, Zheng K, Rachman F, Gans DN, Tanner C. Use of a Comprehensive Patient Safety Tool in Primary Care Practices. J Am Assoc Nurse Pract 2013; 25 (08) 415-418.
• 20 Lesar T, Mattis A, Anderson E, Avery J, Fields J, Gregoire J, Vaida A. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf 2003; 29 (05) 211-226.
• 21 Smetzer JL, Vaida AJ, Cohen MR, Tranum D, Pittman MA, Armstrong CW. Findings from the ISMP Medication Safety Self-Assessment for hospitals. Jt Comm J Qual Saf 2003; 29 (11) 586-597.
• 22 The development of this instrument was supported by a grant from the Commonwealth Fund to the Health Research and Education Trust (HRET), the Institute for Safe Medication Practices (ISMP) and the Medical Group Management Association (MGMA). It was modeled on a similar tool developed for the acute hospital setting by the ISMP ( http://www.ismp.org/selfassessments/Hospital/2004Hosplrg.pdf ). To view the self-assessment along with its constituent items, visit http://www.mgma.com/pppsa.
• 23 Heisey-Grove D, Patel V. Physician Motivations for Adoption of Electronic Health Records. ONC Data Brief, no. 21. Washington DC: Office of the National Coordinator for Health Information Technology; Dec 2014. http://www.healthit.gov/policy-researchers-implementers/briefs . Accessed January 14, 2015