Tuesday, January 17, 2012

This Strikes Me As Something That Might Be Missing From The PCEHR Program - An Exploration and Analysis of the Downsides and Risks!

The following news release appeared a little while ago and I spotted in the monthly RAND newsletter.

Online Guide Helps Health Organizations Adopt Electronic Health Records

Wednesday
December 14, 2011
A new online guide is available from the U.S. Agency for Healthcare Research and Quality to help hospitals and other health care organizations anticipate, avoid and address problems that can occur when adopting and using electronic health records.
The free tool, called the "Unintended Consequences Guide," was created to provide practical troubleshooting knowledge and resources. Experts from the RAND Corporation, the University of Pennsylvania School of Medicine, Kaiser Permanente-Colorado and the American Health Information Management Association Foundation created the guide. The work was supported by a contract from the Agency for Healthcare Research and Quality.
The guide can be found at www.ucguide.org.
"The goal is to provide administrators, technology officers and health care providers with information that will help them successfully adopt and use electronic health records," said Spencer Jones, an information scientist at RAND and a co-author of the guide. "Moving from paper records to electronic records is a major undertaking and the 'Unintended Consequences Guide' is an essential tool to help that migration."
"One of the purposes in funding this effort was to help health IT implementers understand the interactions between humans and technology that are often the source of unintended consequences," said Michael Harrison, a senior social scientist with the Agency for Healthcare Research and Quality and a collaborator on the guide.
"Having recently completed the largest civilian roll out of a national electronic health record system in the United States, we want to share our knowledge about implementation and how electronic records can transform health care delivery," said Dr. Ted Palen of the Kaiser Permanente-Colorado Institute for Health Research.
Use of electronic health records is growing rapidly among hospitals and other health care providers in the United States, spurred in part by major federal investments in the technology. Legislation approved in 2009 eventually may provide as much as $30 billion in federal aid to hospitals and physicians that invest in electronic health records. The guide was developed for use by all types of health care organizations — from large hospital systems to solo physician practices.
The creators anticipate that the primary users will be those responsible for adopting electronic health records, including federally designated Regional Extension Centers, chief information officers, directors of clinical informatics, electronic health records "champions" or "super users," administrators, information technology specialists and clinicians involved in adoption of the technology. Frontline users of electronic health records such as physicians and nurses also may also find the guide useful.
The online resource is based on the research literature, other practice-oriented guides for electronic health record adoption, research by its authors and interviews with leaders of organizations that have recently switched to electronic health records. The guide represents a compilation of the known-best practices for anticipating, avoiding and addressing unintended consequences of adopting electronic health records. However, researchers say, this area of research is still in its infancy.
RAND Health, a division of the RAND Corporation, is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care costs, quality and public health preparedness, among other topics.
You can find the press release here:
If you visit the site you will find a wealth of very, very useful material.
In the introduction to the site the authors have the following to say:

Guide to Reducing Unintended Consequences of Electronic Health Records

The Guide to Reducing Unintended Consequences of Electronic Health Records is an online resource designed to help you and your organization anticipate, avoid, and address problems that can occur when implementing and using an electronic health record (EHR). Our purpose in developing the Guide was to provide practical, troubleshooting knowledge and resources.
The Guide was developed with all types of health care organizations in mind — from large hospital systems to solo physician practices. We anticipate that the primary users will be EHR implementers such as Regional Extension Centers, chief information officers, directors of clinical informatics, EHR champions or "super users," administrators, information technology specialists, and clinicians involved in the implementation of an EHR. Frontline EHR users (such as physicians and nurses) may also find the Guide useful.
The Guide is based on the research literature, other practice-oriented guides for EHR implementation and use, research by its authors, and interviews with organizations that have recently implemented EHR. The Guide represents a compilation of the known best practices for anticipating, avoiding, and addressing EHR-related unintended consequences. However, this area of research is still in its infancy. Therefore, the Guide is a work in progress. We invite you to revise its tools and recommendations in keeping with your own experience and in response to emerging research findings.
The full resource is found here:
The following question and answer makes it clear what is being addressed:

Question 2: What are some examples of unintended consequences?

Here are some examples of common unintended consequences:
1.       More work for clinicians
Example: After the introduction of an EHR, physicians often have to spend more time on documentation because they are required to (and facilitated to) provide more and more detailed information than with a paper chart. While this information may be helpful, the process of entering the information may be time consuming, especially at first.
2.       Unfavorable workflow changes
Example: Computerized physician order entry (CPOE) automates the medication and test ordering process by reducing the number of clinicians and clerical staff involved, but by doing so it also eliminates checks and counterchecks in the manual ordering process. That is, with the older system, nurses or clerks may have noticed errors, whereas now the order goes directly from the physician to the pharmacy or lab.
3.       Never-ending demands for system changes
Example: As EHRs evolve, users rely more heavily on the software, and demand more sophisticated functionality and new features (e.g., custom order sets). The addition of new functionalities necessitates that more resources be devoted to EHR implementation and maintenance.
4.       Conflicts between electronic and paper-based systems
Example: Physicians who prefer paper records annotate printouts and place these in patient charts as formal documentation, thus creating two distinct and sometimes conflicting medical records.
5.       Unfavorable changes in communication patterns and practices
Example: EHRs create an "illusion of communication," (i.e., a belief that simply entering an order ensures that others will see it and act upon it.) For example, a physician fails to speak with a nurse about administering a medication, assuming that the nurse will see the note in the EHR and act upon it.
6.       Negative user emotions
Example: Physicians become frustrated with hard-to-use software.
7.       Generation of new kinds of errors
Example: Busy physicians enter data in a miscellaneous section, rather than in the intended location. Improper placement can cause confusion, duplication, and even medical error.
8.       Unexpected and unintended changes in institutional power structure
Example: IT, quality assurance departments, and the administration gain power by requiring physicians to comply with EHR-based directives (e.g., clinical decision support alerts).
9.       Overdependence on technology
Example: Physicians dependent on clinical decision support may have trouble remembering standard dosages, formulary recommendations, and medication contraindications during system downtimes.
Source: Campbell, EM, Sittig DF, Ash JS, et al. Types of Unintended Consequences Related to Computerized Provider Order Entry. J Am Med Inform Assoc. 2006 Sep-Oct; 13(5): 547-556.
More here:
Consideration of this list in the light of the current PCEHR proposals might be a very sensible idea to see just how badly the present PCEHR proposal is likely to perform.
Browsing the other pages is just fascinating to see just how many traps there are that we already know about and should be planning to avoid.
The External Resources link is especially useful
RAND, the AHRQ and the US Department of Human Services deserve thanks for making this invaluable resource available.
David.

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