While futurists and tech enthusiasts may look forward to the day when artificial intelligence can recommend cancer treatments, or to a future when a chip implanted in your arm can keep you updated on key biomarkers, the healthcare world is still adjusting to a much more basic technology: electronic health record (EHR) systems.
EHRs are used extensively by physicians, clinics, and hospitals, who enter their patients’ information into the platform to track their data and to occasionally provide alerts and advice. They promise to make healthcare more efficient and less expensive, and even have the potential to improve the quality of care that patients receive by making their medical history available to all of the professionals who treat them. But flaws both in the EHR systems themselves and in the workflows that medical professionals have reconfigured around them raise the question of whether the technology is really making healthcare safer, or if it simply introduces more opportunity for error.
Arthur Allen recently reported for Politico that medical errors connected to the automation of healthcare are increasingly factoring in to medical malpractice lawsuits. When the U.S. government began incentivizing the implementation of EHRs in 2009, officials predicted that electronic records would improve patient safety by making patients’ medical charts legible and accessible.
The $30 billion the government has spent in the past five years has succeeded in rapidly raising the adoption rate of EHRs. But Allen reports that doctors, attorneys, and health tech experts involved in EHR-related malpractice litigation think that problems with safety and data integrity could “undercut the benefits of electronic health records unless HHS and Congress address them aggressively.”
According to a review by The Doctors Company, the largest physician-owned medical malpractice insurer in the United States, EHR issues were involved in only 1% of a sample of lawsuits that concluded between 2007 and 2013. But Allen points out that the statistic could be deceptive given the fact that it takes five or six years to close a suit. During the same period, EHRs became more pervasive in hospitals and physicians’ offices, and the number of cases involving EHR issues grew rapidly. In fact, the pace of such cases doubled from 2013 to early 2014.
The lawsuits involve allegations of a range of mistakes and information gaps, such as typos that led to medication errors, voice-recognition software that drops key words, doctors’ reliance on incorrect records, and nurses’ misinterpretation of dropdown menus. And discrepancies between what doctors and nurses see on their computer screens and the printouts of electronic records add complexity, as printouts often don’t reflect the decision options offered on medical staff’s screens through dropdown menus, prompts, and alarms.
The data on whether EHRs make hospitals safer is inconclusive, and their effect on malpractice insurance is also unclear. Allen reports that in the approximately 200 EHR-related legal cases that the liability firm CRICO analyzed, EHR glitches rarely led directly to patient harm. But Dana Siegal, the company’s director of patient safety services, said the company observed errors that resulted from “failures to communicate or providers acting on inaccurate information that was driven in part by an EHR issue.”
The ways that EHRs cause problems are often difficult to diagnose thanks to the complex interaction of technology and medical practice. Errors often stem from the way a program was installed or the way doctors were trained to use it. Vendors blame issues with data integrity on the client’s implementation. But shifting blame doesn’t help resolve the errors, which in some cases have dangerous consequences.
Robert Wachter, in a series of posts titled “The Overdose” for Backchannel, recounted the chain of events in which an error that originated in his hospital’s EHR prompted medical professionals to give a teenager a 39-fold overdose of a common antibiotic. He wrote of the incident several months ago for The New York Times, “The initial glitch was innocent enough: A doctor failed to recognize that a screen was set on ‘milligrams per kilogram’ rather than just ‘milligrams.’ But the jaw-dropping part of the error involved alerts that were ignored by both physician and pharmacist. The error caused a grand mal seizure that sent the boy to the I.C.U. and nearly killed him.”
Wachter reports that EHRs show medical professionals “tens of thousands” of alerts every month — the vast majority of them false alarms — and many providers grow numb to them. And while dangerous errors and frustrating workflow bottlenecks have prompted some physicians to suggest that the medical world should return to pen and paper, Wachter thinks that that argument is “utterly unpersuasive.”
Wachter thinks that changes both in the technology and in the workforce are necessary for electronic records systems to live up to their potential and reduce the errors and vast costs associated with medical care. He argues that healthcare is the most information-intensive industry, and “We will never make fundamental improvements in our system without the thoughtful use of technology. Even today, despite the problems, the evidence shows that care is better and safer with computers than without them.”