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Search results for "Electronic Health Records"

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Journal Article > Study

Prognosis of undiagnosed chest pain: linked electronic health record cohort study.

Jordan KP, Timmis A, Croft P, et al. BMJ. 2017;357:j1194.

Missed and delayed diagnoses are an increasingly recognized patient safety problem. A common undiagnosed symptom in outpatient medicine is chest pain. This retrospective cohort study compared outcomes for three groups of patients with chest pain: those whose pain remained undiagnosed after 6 months versus those diagnosed with either coronary artery disease or a verified noncardiac cause of chest pain. Only a minority of the undiagnosed patients underwent diagnostic testing for coronary artery disease. The highest risk of myocardial infarction was in patients with diagnosed coronary artery disease, but undiagnosed patients were more likely to have a myocardial infarction than those with verified noncardiac disease. The authors conclude that patients without a timely diagnosis merit further evaluation to reduce the risk of cardiovascular events.

Journal Article > Study

Innovative use of the electronic health record to support harm reduction efforts.

Hyman D, Neiman J, Rannie M, Allen R, Swietlik M, Balzer A. Pediatrics. 2017;139:e20153410.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for certain hospital-acquired conditions—an increasingly recognized source of preventable harm to patients. Researchers describe how they were able to reduce harm resulting from hospital-acquired conditions at their institution by more than 30% through improved use of electronic health record data and reporting tools.

Cases & Commentaries

Patient Allergies and Electronic Health Records

  • Web M&M

Matthew J. Doyle, MBBS; April 2017

Prior to undergoing a CT scan, a patient with no allergies documented in the electronic health record (EHR) described a history of hives after receiving contrast. During a follow-up clinic visit, the patient inquired whether this contrast reaction was listed in the EHR. Investigation revealed that it had been removed from the patient's profile, thus leaving the record with no evidence of allergy to contrast.

Cases & Commentaries

Unexpected Drawbacks of Electronic Order Sets

  • Web M&M

John D. McGreevey III, MD; November 2016

A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.

Journal Article > Study

Rising drug allergy alert overrides in electronic health records: an observational retrospective study of a decade of experience.

  • Classic

Topaz M, Seger DL, Slight SP, et al. J Am Med Inform Assoc. 2016;23:601-608.

Alert fatigue is recognized as a barrier to patient safety and may particularly increase risks associated with medication prescribing. This study examined the frequency of manual overrides of alerts for medication allergies over a 10-year period. Clinicians were required to provide a reason for overriding the allergy alert. As with earlier studies, the rate of overrides was very high. Researchers determined that the alerts were irrelevant in more than half the cases. Providers also were more likely to override repeated alerts compared with new alerts. These results highlight the overuse of alerts in health care settings and the need to improve their use to effectively support patient safety.

Cases & Commentaries

The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy

  • Spotlight Case
  • CME/CEU
  • Web M&M

Jacob Reider, MD; October 2015

After leaving Hospital X against medical advice, a man with paraplegia presented to the emergency department of Hospital Y with pain and fever. The patient was diagnosed with sepsis and admitted to Hospital Y for management. In the night, the nurse found the patient unresponsive and called a code blue. The patient was resuscitated and transferred to the ICU, where physicians determined that the arrest was due to acute rupturing of his red blood cells (hemolysis), presumably caused by a reaction to the antibiotic. Later that day, the patient's records arrived from three hospitals where he had been treated recently. One record noted that he had previously experienced a life-threatening allergic reaction to the antibiotic, which was new information for the providers at Hospital Y.

Journal Article > Study

Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial.

  • Classic

Murphy DR, Wu L, Thomas EJ, Forjuoh SN, Meyer AND, Singh H. J Clin Oncol. 2015;33:3560-3567.

Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.

Journal Article > Commentary

A piece of my mind. Writing the wrong.

Patel JJ. JAMA. 2015;314:671-672.

Despite the potential for electronic health record (EHR) systems to improve access to patient data, unintended consequences have emerged that can hinder information seeking. To highlight how EHRs can detract from patient–physician relationships, this commentary reveals insights from a physician who failed to notice a patient's respiratory failure and distress due to over-reliance on the EHR.

Journal Article > Study

Patient–doctor continuity and diagnosis of cancer: electronic medical records study in general practice.

Ridd MJ, Santos Ferreira DL, Montgomery AA, Salisbury C, Hamilton W. Br J Gen Pract. 2015;65:e305-e311.

A delayed or missed diagnosis of cancer can have profound ramifications for patients. This retrospective cohort study in England sought to determine whether patient–doctor continuity in the ambulatory setting affected the time to diagnosis or referral for three common cancers. The researchers used a large reliable dataset for patients with a diagnosis of breast, colorectal, or lung cancer between January 2000 and December 2009. They searched for any relevant cancer symptoms or signs up to 12 months prior to the diagnosis and calculated patient–doctor continuity for up to 2 years before diagnosis. The measured associations appeared small and inconsistent, suggesting no clinically important differences. The longest delays for diagnosis occurred after patients had been referred for consultation, indicating that future studies should focus on the process of care between referral and diagnosis.

Journal Article > Commentary

Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.

Upadhyay DK, Sittig DF, Singh H. Diagnosis (Berl). 2014;1:283.

Misdiagnosis and errors linked to electronic health records (EHRs) are common concerns in patient safety. This commentary examines these elements in the context of the first Ebola case in the United States to reveal weaknesses in emergency department care, disaster management, and diagnostic processes. The case analysis highlights challenges associated with forming diagnoses and the usability of EHRs as decision support tools.

Journal Article > Study

Personal health records: a randomized trial of effects on elder medication safety.

Chrischilles EA, Hourcade JP, Doucette W, et al. J Am Med Inform Assoc. 2014;21:679-686.

More than half of older adults offered access to personal health records (PHRs) logged on at least once, but frequent use was rare. While users reported improved medication reconciliation and safety behaviors, there was no difference in use of inappropriate medications or adherence measures compared with patients who had no access to PHRs.

Journal Article > Study

Exploring the sociotechnical intersection of patient safety and electronic health record implementation.

  • Classic

Meeks DW, Takian A, Sittig DF, Singh H, Barber N. J Am Med Inform Assoc. 2014;21:e28-e34.

Electronic health record (EHR) implementation can be associated with both risks and improvements in safety. This study sought to characterize the positive and negative safety implications of EHR implementation and ongoing use by analyzing interview data from a 30-month evaluation of EHR implementation at 12 sites in the United Kingdom's National Health Service. The study demonstrates how eight specific human–technological factors in a sociotechnical model (people, workflow and communication, internal organizational features, external rules and regulation, measurement and monitoring, hardware and software, clinical content, human–computer interface) come into play in moving health care organizations through three phases of technology implementation. Safety hazards may be introduced in early phases of EHR implementation phases, and inappropriate use of technology as implementation progresses can also result in risks. When EHR use has stabilized, the technology can be used to promote safety.

Journal Article > Study

A typology of electronic health record workarounds in small-to-medium size primary care practices.

Friedman A, Crosson JC, Howard J, et al. J Am Med Inform Assoc. 2014;21:e78-e83.

This ethnographic study used direct observation to characterize how users of an electronic health record compensated for perceived system deficiencies.

Journal Article > Study

Electronic health record-based triggers to detect potential delays in cancer diagnosis.

Murphy DR, Laxmisan A, Reis BA, et al. BMJ Qual Saf. 2014;23:8-16.

Delayed diagnoses in cancer may commonly be caused by cognitive errors or logistical breakdowns. These delays can lead to poor patient outcomes and are a frequent cause of malpractice lawsuits in the ambulatory setting. In this study, four electronic triggers were developed to detect patients at risk for delayed diagnosis of prostate and colorectal cancers. The algorithm identified patients with elevated prostate-specific antigen levels, positive fecal occult blood tests, iron-deficiency anemia, or bright red blood per rectum, but automatically excluded those that already received appropriate care or had known terminal illnesses. The positive predictive values for each these triggers were between 58% and 70%, providing a reasonably accurate report of patients that truly lacked appropriate follow-up. The American Medical Association has identified better follow-up of abnormal test results as a key area for improving patient safety in the ambulatory setting.

Journal Article > Study

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions.

Flanagan ME, Saleem JJ, Millitello LG, Russ AL, Doebbeling BN. J Am Med Inform Assoc. 2013;20:e59-e66.

This ethnographic study used direct observations in 11 primary care clinics with an integrated electronic health record (EHR) to characterize the extent and types of workarounds used by clinicians and support staff. As with prior classic research, the investigators found several different types of paper- and computer-based workarounds, with most being used to aid memory, improve efficiency, or enhance provider awareness of specific clinical problems. For example, several instances of copying and pasting clinical information from note to note were observed, despite this practice being against the institution's policy. Workarounds are generally regarded as representing EHR design failures, but the authors argue that it is unrealistic to expect EHRs to completely obviate the need for paper-based cognitive aids. They advocate for incorporating data on common types of workarounds into human factors–based approaches to improving EHR usability.

Journal Article > Study

Information overload and missed test results in electronic health record–based settings.

Singh H, Spitzmueller C, Petersen NJ, Sawhney MK, Sittig DF. JAMA Intern Med. 2013;173:702-704.

Prior research has shown that delayed follow-up of test results is still common even within electronic health records. This survey of primary care physicians in the Veterans Affairs system found that the majority reported receiving more alerts (a mean of 63 per day) than they could effectively manage and that missed or delayed result follow-up was common.

Journal Article > Study

Patient safety perceptions of primary care providers after implementation of an electronic medical record system.

McGuire MJ, Noronha G, Samal L, Yeh HC, Crocetti S, Kravet S. J Gen Intern Med. 2013;28:184-192.

Electronic medical records (EMRs) are generally perceived to improve patient safety, and prior reviews have found that EMR implementation is associated with improvement in some measures of safety and quality. This study of EMR implementation in a large primary care medical group found a positive association between implementation of a new EMR and safety culture, with sustained improvement in Safety Attitudes Questionnaire scores over a 3-year period following implementation. Interestingly, the perceived improvement in safety culture was smallest in the first year of use of the new EMR; a prior study found that 1 year of experience was necessary before primary care physicians felt a new EMR improved safety and quality.

Cases & Commentaries

Sloppy and Paste

  • Web M&M

Robert Hirschtick, MD; July 2012

An elderly man presented to an emergency department (ED) with new onset chest pain. In reviewing the patient's electronic medical record (EMR), the ED physician noted a history of "PE," but the patient denied ever having a pulmonary embolus. Further investigation in the EMR revealed that, many years earlier, the abbreviation was intended to stand for "physical examination." Someone had mistakenly copied and pasted PE under past medical history, and the error was carried forward for years.

Journal Article > Study

Medication safety in primary care practice: results from a PPRNet quality improvement intervention.

Wessell AM, Ornstein SM, Jenkins RG, Nemeth LS, Litvin CB, Nietert PJ. Am J Med Qual. 2013;28:16-24.

A multimodal quality improvement project based in a shared electronic medical record resulted in a decrease in potential adverse drug events in 20 primary care practices.

Journal Article > Study

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011.

Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2012;69:768-785.

Hospitals' use of electronic medical records and computerized provider order entry (CPOE) continues to increase relatively slowly. However, this annual survey of more than 1400 hospitals by the American Society of Health-System Pharmacists found that uptake of medication safety technology has quickened. Half of responding hospitals reported using barcode medication administration, and more than two-thirds use electronic medication administration records and smart infusion pumps. In contrast, a much smaller proportion of hospitals reported using CPOE. These findings indicate that hospitals overall are incorporating new technologies proven to reduce the risk of medication errors.

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