R E V I E W S & A N A LY S E S Spotlight on Electronic Health Record Errors: Paper or Electronic Hybrid Workflows Erin Sparnon, MEng INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority The Pennsylvania Patient Safety Authority published an analysis of patient safety events related to the use of electronic health records (EHRs) reported through the state’s man- datory reporting system in the December 2012 issue of its Pennsylvania Patient Safety ABSTRACT Advisory.1 This research was motivated in part by the 2011 Institute of Medicine (IOM) In a previous Pennsylvania Patient Safety report Health IT and Patient Safety: Building Safer Systems for Better Care,2 which noted a Advisory article, analysts read 3,099 lack of hazard and risk reporting data on health information technology (HIT). The narrative reports relevant to health IOM report considered this lack of reporting data to be a hindering factor in ongoing information technology (HIT) from the efforts to improve the safety of HIT systems. The Advisory article identified EHR-related Pennsylvania Patient Safety Authority's events reported through the Authority’s Pennsylvania Patient Safety Reporting System database and tagged each report using database and applied a previously published classification taxonomy specific to HIT.3 a previously published classification In the course of manually reviewing EHR-related reports in the Authority’s database, taxonomy developed specifically for HIT. analysts identified several general error types and trends that warranted further study. In the course of that review, analysts In this article, analysts focus on errors related to hybrid medical records workflows, in identified 85 reports of a specific type of which a mix of paper and electronic media is used to maintain the medical records for error: errors related to miscommunica- a single patient. These errors largely include omission and duplication of tasks due to tion arising from dual use of electronic miscommunication among caregivers and can pose serious risk to patients. and paper documentation. The use of a hybrid workflow, in which both elec- tronic and paper systems are used for METHODS documentation, is often found in care The 85 cases used in this analysis were identified from a prior data set of 3,099 areas transitioning from a paper-based EHR-related incident reports queried for the December 2012 Advisory article. Shortly to fully electronic (i.e., electronic health after beginning the manual review of queried event reports for the December article, record [EHR]) documentation proce- analysts noticed several reports that dealt with miscommunication due to dual use dure. Hybrid workflows may occur as of electronic and paper documentation practices, an error type that did not neatly fit a planned transitional step during the into any one category of the Magrabi et al. error classification taxonomy used in the implementation of an EHR system or December analysis.3 Analysts then created a tag for this type of hybrid-workflow error may arise as a workaround in which and considered it for each of the 3,099 manually reviewed reports that were deemed paper is used to supplement electronic relevant to EHRs, identifying 85 reports relevant to hybrid workflows. systems. This article describes the type of events related to the use of a hybrid RESULTS workflow and provides recommenda- tions on reducing the use of hybrid Classification by Harm Score workflows. (Pa Patient Saf Advis 2013 Of the 85 identified reports, 77 (91%) were reported as “event, no harm” (i.e., an error Jun;10[2]:55-8.) did occur, but there was no adverse outcome for the patient) and 7 (8%) were reported as “unsafe conditions” that did not result in a harmful event. Only one report involved temporary harm to the patient related to receiving the wrong dosage form (extended- release instead of standard tablets) of a narcotic: Physician ordered “Oxycodone 30 mg PO q 4 h [by mouth, every four hours].” At 0600, that order was entered in [the computerized order entry (CPOE) system] as “Oxycodone ER [extended release] 30 mg PO q 4 h” and verified in Meditech by RN [registered nurse]. That was then administered by nine different nurses. The paper MAR [medication administration record] that pharmacy viewed and verified was actually done correctly stating “Oxycodone 30 mg PO q 4 h.” The order in [the CPOE system] was never verified by pharmacy. In this case, it appears that the pharmacy did not have access to the electronic order, and the solution would be to redesign workflow so that the pharmacy verifies orders printed from the CPOE. Overall, the harm score pattern for reports related to hybrid paper and electronic workflows closely resembled the harm score pattern for all EHR- related reports identified in the December 2012 article. Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 55 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Classification by Event Type orders are also not present on [the compile the legal patient record from Of the 85 identified reports, the most CPOE system]. both paper and electronic sources at the commonly used event type assigned by [Patient] ordered heparin through end of every day, stressing HIM resources reporters was “medication error” (n = 63, PE/DVT [pulmonary embolism/ and doubling the time to perform release- or 74% of reports). Within medication deep-vein thrombosis] assessment of-information requests.9 In order to errors, the most commonly used event order sheet. Med entered in pharmacy meet the logistical and legal challenges of type classification was “wrong medica- information system but not tran- hybrid workflows, facilities need to create tion” (22%), followed by “dose omission” scribed to Kardex or current MAR for and maintain documentation of where (19%) and “extra dose” and “other” (each administration. Dose overlooked. No different pieces of their medical records with 13%). harm reported. are stored.10 In designing this documen- tation process, facilities may wish to Extra Dose or Overdose conduct a comprehensive workflow analy- DISCUSSION sis on the process of accessing all the data Events classified by the reporter as Hybrid workflows may arise by design required to fulfill release of information “extra dose” (n = 11) , as well as 5 of the as a necessary transitional state between requests.11 19 events classified as wrong-medication all-paper and all-electronic workflows or errors, included reports of potential over- Avoiding the challenges of a hybrid system as an unintended workaround. Although doses related to miscommunication as to may include preventing one from devel- meaningful use incentives have increased whether a patient had already received a oping: instead of lingering in a hybrid EHR adoption projects in the last several medication, such as the following: transitional state, facilities may wish to years,4 these projects do not always lead focus on finishing the transition from a Written order for Toradol [ketorolac smoothly to fully electronic workflows.5 wholly paper to a wholly electronic work- tromethamine] 30 mg on patient’s Funding gaps, competing priorities, and flow as completely and in as short a time emergency room chart. Medication a lack of industry education have left frame as possible. The American Health administered by nurse and docu- many facilities in extended or indefinite Information Management Association mented in electronic medical record, transitional periods in which both paper considers a complete transition from a not on paper emergency room chart. and electronic systems are maintained.6 paper to EHR system to be best practice Second nurse also saw order and Even in a nominally all-electronic work- and offers practical advice for ensuring administered medication again. flow, hybrid workflows can arise as a the quality and integrity of a facility’s workaround if clinicians supplement use legal health record throughout the transi- Dose Omission of an electronic system with handwrit- tion period, including factors to consider Events related to dose omission medica- ten notes as documentation aids.7 The when developing policies and procedures tion errors (n = 16) included six reports ways in which hybrid workflows are used for when electronic information can be related to orders or documentation are likely to be unique to each facility or printed out in a hybrid environment:6 written on paper but never entered into care area, with differences arising from a electronic systems and seven reports combination of EHR functionality, local — Timeliness, as paper printouts will of electronic orders not being properly workflows, and organizational policies not contain updated electronic printed or written onto the paper medi- and procedures.8 information. cation administration worksheets (e.g., Hybrid workflows raise the potential for — Money spent on generating, manag- Kardex) used by clinicians. Examples of medical error: if clinicians need to check ing, securing, and destroying papers, these two types of errors are as follows: for information in multiple locations, compact discs, external storage clinicians may be more likely to overlook drives, and other media could be Orders in paper chart were not trans- some information.4 Hybrid systems also better spent on making sure access to ferred to computer. These included pose logistical and legal challenges for electronic information is pervasive. “NPO till procedure completed, 1 gm Ancef [cefazolin] IV [intravenous] facilities. A 2008 study of Indian Health — Risk of allowing users to make notes on call to OR [operating room] . . ., Service (IHS) clinics in Billings, Montana, on paper copies, which would then and VS q15 x 4.” These had been found that allowing providers to choose need to be retained as part of the written on paper chart at 1800. The between using paper and electronic legal health record and could lead Ancef was not profiled on MAR, systems as they transitioned to an EHR to confusion when the paper record and the rest of the aforementioned system required health information man- and the electronic record contain agement (HIM) staff to complete and different information. Page 56 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority Barriers and facilitators for EHR adoption — Designing and carrying out pilot test- the type of reports included: they were can arise from many factors, including ing in enough clinical locations so selected during manual review of reports system, user, organizational, and environ- that the results can be applied to the identified through a query intended mental attributes, as well as support from remainder of the facility to identify EHR-related events. There others.12 Technical design of the system is — Seeking appropriate participation are likely many more reports in the key, as usability and usefulness can signifi- from end users (e.g., nurses, physi- Authority’s database related to miscom- cantly impact staff acceptance and use.13 cians, other caregivers) in all phases munication while using hybrid paper and However, the nontechnical details of of the implementation electronic workflows; however, this type of the implementation of a new electronic — Continually evaluating the safety and error is a complex issue not amenable to system (e.g., policy development, manage- effectiveness of implemented sys- simple query searching. ment of the workflow changes required tems, including error reporting and for the transition) may be just as impor- incident investigation CONCLUSIONS tant as the design of the system itself,14 Additional resources for successful EHR This analysis indicates that hybrid and a review of best-practice literature for implementation planning are avail- workflows contribute to medical errors technology implementation identified able from many groups, including the reported to the Authority. Use of a hybrid several key components for the successful Healthcare Information Management workflow can lead to miscommunication design and implementation of new elec- Systems Society,17 the United Kingdom’s among caregivers when orders and admin- tronic systems:15,16 National Health Service,18 the Office of istration information differ between paper — Identifying a single person who is the National Coordinator for Health and electronic systems. This miscommuni- responsible and accountable for the Information Technology’s regional exten- cation can lead to medication errors like implementation’s success sion offices for support of small rural and dose omissions and extra doses, which can critical access hospitals,19 and the Agency cause serious harm to patients. Therefore, — Selecting an EHR technology plat- for Healthcare Research and Quality facilities should consider the implications form that can meet workflow needs, (AHRQ).20 Specific AHRQ resources of hybrid documentation workflows, espe- configuring its user interface to relevant to this article include a report on cially if they are facing a recent or planned permit users to safely and efficiently mitigating the unintended consequences implementation of EHR systems. Facili- grasp a complex process, and popu- of EHR implementation,21 a toolkit for ties that have transitioned to EHR systems lating the EHR system with content workflow assessment in HIT,22 and a may wish to periodically monitor clinical that is relevant to clinical practice searchable knowledge library.23 workflow to determine whether hybrid — Studying current, pre-electronic workflows are developing in response to workflows to determine what user challenges with the electronic system. changes will be needed when moving Limitations to an electronic workflow The provenance of the data set used as the basis of this report may have shaped NOTES 1. Sparnon E, Marella WM. The role of 3. Magrabi F, Ong MS, Runciman W, et al. the transition from paper to EHRs the electronic health record in patient Using FDA reports to inform a classifica- [practice brief online]. 2010 Nov safety events. Pa Patient Saf Advis tion for health information technology [cited 2013 Apr 12]. http://library. [online] 2012 Dec [cited 2013 May 1]. safety problems. J Am Med Inform Assoc ahima.org/xpedio/groups/public/ http://patientsafetyauthority.org/ 2012 Jan-Feb;19(1):45-53. documents/ahima/bok1_048418. ADVISORIES/AdvisoryLibrary/2012/ 4. Sittig D, Singh H. Electronic health hcsp?dDocName=bok1_048418. Dec;9(4)/Pages/113.aspx. records and national patient-safety goals. 7. Park SY, Lee SY, Chen Y. The effects of 2. Institute of Medicine. Health IT and N Engl J Med 2012 Nov 8;367(19):1854-60. EMR deployment on doctors’ work prac- patient safety: building safer systems 5. Chavis S. Pulling double duty [online]. tices: a qualitative study in the emergency for better care [report online]. 2011 For the Record 2011 Sep 26 [cited 2013 department of a teaching hospital. Int J Nov 8 [cited 2013 Jan 18]. http:// Feb 19]. http://www.fortherecordmag. Med Inform 2012 Mar;81(3):204-17. www.iom.edu/Reports/2011/ com/archives/092611p24.shtml. 8. 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