Two Health IT Hazards To Avoid

By Ken Congdon, Editor In Chief, ken.congdon@jamesonpublishing.com
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When implemented correctly, health IT systems can increase clinical efficiencies, reduce operational costs, and improve patient care. However, many sophisticated health IT solutions can also pose substantial risks to a hospital and its patients if applied improperly or mismanaged. ECRI Institute recently highlighted some of the top health IT dangers to be mindful of in its report titled Top 10 Health Technology Hazards For 2013. Two of the top 10 hazards referenced in this report — EHR Patient Data Mismatches and Mobile Device Distractions — were particularly interesting to me.

EHR Patient Data Mismatches

EHR systems are intended to create an electronic patient record that is easily updated, accessed, and transmitted to ensure proper patient treatment and care coordination. These systems can also incorporate alarms and other clinical decision support tools to ensure clinicians consider all options when diagnosing and treating patients. However, what happens if data from one patient accidentally becomes associated with another patient’s electronic record? This troubling question is posed in ECRI’s report.

As the authors indicate, patient data errors are not a new phenomenon. Even with paper records, data from one patient can easily wind up in another patient folder as a result of human error. However, according to ECRI Institute, some of the capabilities that make EHRs so powerful (e.g. their ability to collect and transmit data to a variety of other devices and systems) can multiply the negative effects of such errors. ECRI’s research and testing confirms that patient/data association errors not only occur with EHRs, but these errors can actually result from system design flaws or software anomalies as opposed to mere user error.

To prevent these types of errors from occurring, ECRI Institute recommends the following actions:

• When assessing EHR systems for purchase, consider how all the connected technologies facilitate placing the correct patient data into the correct record. Options may include choosing a patient from a pick list or scanning a bar code on a patient’s wristband.
• Consider both patient flow and device movement in your EHR implementation and plan for all anticipated types of data transfers, not just routine examples.
• Prior to implementing or upgrading your EHR, perform the appropriate testing to verify that the system will function as expected, with the correct data flowing into the proper record for various clinical workflows.     

Mobile Device Distractions

Mobile devices provide clinicians with the ability to access data on the go and at the bedside, improving staff productivity and the overall patient experience. However, as ESRI Institute points out, mobile devices can also easily distract clinicians from their job duties, producing potentially catastrophic consequences.

I initially addressed this concerning byproduct of mobile device usage in a March 2012 article titled iPhones & iPads: A Medical Liability? Many mobile-related clinical distractions are a result of the BYOD (bring your own device) phenomenon — a trend where physicians use their personal smartphones or tablets on the job. When this strategy is deployed, the lines between a doctor's professional and private lives can become blurred. In other words, the physician can easily become distracted by a barrage of text messages, emails, Facebook notifications, tweets, and other personal communications that automatically pop up on the screen.

One actual (and now well-documented) event clearly illustrates the devastating implications these mobile distractions can have. The example involves a female resident on rounds and a 56 year-old patient admitted to have a feeding tube replaced. The resident noticed that the patient was on a blood thinner and decided to enter an order to stop this drug via her smartphone. However, during the order entry process, the resident received a text about a party. She became so consumed about RSVP-ing that she never completed the order. The patient nearly died as a result of the oversight.

ECRI Institute recommends the following steps to minimize mobile distractions:

• Educate staff members and independent physicians about the risks associated with the use of smartphones and similar devices. In particular, raise awareness about the potential for digital distractions to affect patient care.
• Develop a mobile device management strategy for your healthcare organization that addresses security considerations. The strategy should specify the appropriate use of mobile devices while caregivers are on active duty, what (if any) network resources the devices can access, which mobile devices are supported, and the measures users must take to ensure their mobile devices are used safely and securely.
• Consider whether or not to restrict personal uses of smartphones and similar devices during patient care activities.