Patients and EHRs: Trust but Verify

June 23, 2014

An unpredictable amount of information in a typical EHR is wrong or meaningless, so it's important for patients to stay on top of their own treatment.

I recently and unexpectedly spent some as a hospital patient. When chatting with the nurses, one topic consumed them: the hospital's computer system and its negative impact on patient care. Their comments were revealing but not surprising: 

• The system forces me to spend my time at the computer when I would rather be with my patients
• I can't talk now, I've got to go enter all this stuff.
• "I wish you could fix our system."

Medication administration is one area that suffers from the constant demands of their computer system. During the 10 days I was hospitalized, I did not receive a single dose of medication at the time it was scheduled. 

By staying alert, I was able to pester the nurses until they pulled themselves away from their computer work, but the doses were often an hour to two hours late. I doubt that every delay was significant but waiting up to two hours for pain meds is not only unpleasant, it violates The Joint Commission's admonition to provide adequate pain control. 

In the case of the antibiotics, there is still disagreement about when or if they are necessary; but if they are to be given, they will only produce the desired effect if given at the proper times. The dosing intervals are selected to provide adequate blood levels between the peaks and troughs. If the trough level drops too far below recommended, the entire treatment plan is jeopardized. What is the point of administering an expensive drug with known risks if the benefit cannot be achieved because it is administered improperly?

Another incident, although trivial, points to a systemic flaw in current EHRs. The data (I use that word only to refer to what gets entered, not to suggest that it means anything) about what meds are given is entered retrospectively from memory or from notes on a paper towel. Couple this with the fact that meds can be ordered with administration options that have no counterpart in the module used to chart the doses given. As happened to me, this sometimes leads to pills being recorded as given when they were not. The "decision support" (Ha!) then concludes that the next dose cannot be given because it "believes" that the patient has already received more drug than they have, in fact, received.

The point of mentioning these incidents is not to accord them undue importance. Rather, when combined with the nurses' comments and their obviously harried state, it seems likely that a great deal of what gets entered into EHRs is probably totally or partially incorrect. If so, the number of errors that are directly attributable to the design and use of the computer must be significant. Under the "right" (wrong) set of coincidences, seemingly innocuous errors may conspire to cause bad outcomes. 

Without more information, I can't apportion blame between the system itself and the way the management has decided to deploy it, the levels of staffing they consider to be adequate and the extent to which the lack of attention to detail allows errors to go undetected and unaddressed. I'm inclined to fault the management for making unrealistic assumptions more than I am to fault the EHR. EHRs are, after all, nothing more than what they are. Any person armed with common sense, who is not blinded by hype or who feels the need to blindly follow orders, could identify these potential problems. They could then avoid the product or use it in a way that avoids its pitfalls.

If an unpredictable amount of what the typical EHR contains is wrong or meaningless, as I believe it is, you can't really expect a physician in a five-minute office visit or at the bedside to fully appreciate the details of your condition and treatment. Furthermore, they have little time to worry about what they don't know. 

The take home lesson is that should you require any healthcare of any kind, you or someone you trust needs to take charge of staying on top of your treatment.