- Electronic health records have a mixed reputation when it comes to patient safety, leading to numerous public and private initiatives to improve usability and implement new features to prevent accidental harm.
The ONC is contributing to these ongoing efforts by releasing a report detailing methodologies for the safe and effective use of “pick lists” for medication management and other ordering tasks.
The report, spearheaded by ONC contractor RTI International, addresses the potential pitfalls of pick lists and drop-down menus, which are widely used in EHR systems, and urges greater standardization and more attention to data integrity throughout the process.
“ONC is committed to continuing other efforts to foster ever-safer health IT and health care as well,” wrote Andrew Gettinger, MD, CMIO and Director of the Office of Clinical Quality and Safety and Marcy Opstal, Health Scientist at the Office of Clinical Quality and Safety.
“One topic we have focused on is pick lists, also known as drop-down lists in an EHR, which are often used when a provider first enters patient information, and subsequently orders prescriptions and dosages for each patient.”
Pick list errors can occur at several different points within the typical workflow, but the report focuses on two of the most common: wrong-patient errors, during which the provider is accessing an incorrect record, and wrong-medication errors, which occur when the user does not select the intended medication from the drop-down list.
Both types of error can be exacerbated by poor EHR optimization and inattentive users, and are especially prevalent in the ambulatory setting, where the majority of prescribing takes place. Inadequate workflow design, alert fatigue, insufficient communication with patients about current medications, and working in multiple charts at the same time can all contribute to patient safety risks.
The report notes, however, that the prevalence of these errors is hard to quantify unless they result in actual harm, leaving EHR designers and optimizers unsure about how to address the issue.
To overcome this problem, the RTI workgroup reviewed a number of existing studies, journal articles, industry discussions, and federally funded reports to gather data on successful case studies and strategies related to medication management, and compiled a number of recommendations and suggestions based on their research.
“The recommendations and resources were developed with a focus on ambulatory care settings, such as doctors’ offices, but many are also appropriate for consideration in other care settings, such as hospitals and long-term care facilities,” Gettinger and Opstal explain.
The report details six major recommendations that cover the general flow of a patient encounter.
Avoid wrong-patient errors by including a photograph of the patient on every screen of the chart. This strategy can help ensure that providers are working with the correct record by triggering provider recall, and may also reduce a variety of other wrong-patient documentation issues.
Use standardized e-prescribing drug name concepts to ensure that users understand which medication they are prescribing no matter which clinical terminology they are most comfortable using. Currently, each drug compendium organization uses different criteria to develop their individual terminology sets, which can cause confusion and errors. Providers, EHR vendors, and other stakeholders should standardize their terminology and develop best practices for displaying information.
Standardize the organization, design, and configuration of all EHR pick lists so that users can easily read and identify options and choose the correct entry in an intuitive manner. Font sizes, spacing, capitalization, and color-coding should all be standardized across drop-down menus to ensure that cognitive dissonance does not result in erroneous selections.
“Advanced features to support pre-population or narrowing the lists of likely patients and medications will streamline selection and reduce scrolling through long lists of items,” the report also suggests, but EHR workflow designers should pay special attention to validation and clinical decision support algorithms that underpin these functions.
Create a summary review screen prior to confirmation of an order. This option will ensure that users have an opportunity to double-check that they have picked the right medication at the correct dosage. While the report “strongly advises” against requiring users to re-enter patient information as part of the confirmation process, the review screen should include the patient’s diagnoses and the medications intended to treat each one as an extra safeguard against mistakes.
Develop user-friendly retract-and-reorder (RAR) capabilities to allow for corrections and gather data on instances when errors occur. “The use of RAR functionality is emerging as a common methodology not only to reverse medication order errors, but also to study incidence and root cause of errors that occur during the medication ordering process, including pick list-related errors,” the report states.
RAR functionalities that cancel orders before they are received and filled by the pharmacy not only improve patient safety, but also prevent staff from investing additional time and manpower in correcting mistakes. Collecting information on when, how, and why RAR functions are triggered can also help to improve the patient safety research process and give quality and safety managers necessary insight into common mistakes.
Engage patients in the process of verifying and updating medication lists by giving all patients a summary of their current medications at each visit. While both CMS and the Join Commission now require providers to deliver an after-visit summary to patients, the report notes that patients don’t always check this information or know what to do with it.
“The information included on the patient summary should reiterate and support the details discussed as part of the ‘teach back’ portion of an office visit, a requirement of the National Patient Safety Goal,” the report states. “If the patient has been given the wrong medication or administration due to a pick list error, careful review of the after-visit summary by the patient is perhaps the most important step in identifying and rectifying the error.”
The report also provides a list of resources for providers interested in further optimizing their electronic health records, and encourages users to identify unique patient safety risks within their own organizations.
The ONC will continue to collect feedback and input from the provider community to improve patient safety and develop strategies to streamline safe medication ordering, Gettinger and Opstal concluded.
“While we continue to advance health IT safety across the board – including by working with Congress to create the Health IT Safety Collaborative – this report and the recommendations developed with a wide range of stakeholders represent an important step to make health IT safer, and more safely used, in all health care settings.”