Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use?

Development and Validation of SafeHIT: An Instrument to Assess the Self-Reported Safe Use of Health Information Technology

BACKGROUND

Implementing health information technology (HIT) may cause unintended consequences and safety risks when incorrectly designed and used. Yet, the tools to assess self-reported safe use of HIT are not well established.

OBJECTIVE

This study aims to develop and validate SafeHIT, an instrument to assess self-reported safe use of HIT among health care practitioners.

METHODS

Systematic literature review and a semistructured interview with 31 experts were adopted to generate SafeHIT instrument items. In total, 450 physicians from various departments at three Malaysian public hospitals participated in the questionnaire survey to validate SafeHIT. Exploratory factor analysis and confirmatory factor analysis (CFA) were undertaken to explore the items that best represent a specific construct and to confirm the reliability and validity of the SafeHIT, respectively.

RESULTS

The final SafeHIT consisted of 14 constructs and 58 items in total. The result of the CFA confirmed that all constructs demonstrated adequate convergent and discriminant validity.

CONCLUSION

A reliable and valid theoretically underpinned measure of determinants of safe HIT use behavior has been developed. Understanding external factors that influence safe HIT use is useful for developing targeted interventions that favor the quality and safety of health care.

The Value of Electronic Health Records Since the Health Information Technology for Economic and Clinical Health Act: Systematic Review

Background

Electronic health records (EHRs) are the electronic records of patient health information created during ≥1 encounter in any health care setting. The Health Information Technology Act of 2009 has been a major driver of the adoption and implementation of EHRs in the United States. Given that the adoption of EHRs is a complex and expensive investment, a return on this investment is expected.

Objective

This literature review aims to focus on how the value of EHRs as an intervention is defined in relation to the elaboration of value into 2 different value outcome categories, financial and clinical outcomes, and to understand how EHRs contribute to these 2 value outcome categories.

Methods

This literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The initial search of key terms, EHRs, values, financial outcomes, and clinical outcomes in 3 different databases yielded 971 articles, of which, after removing 410 (42.2%) duplicates, 561 (57.8%) were incorporated in the title and abstract screening. During the title and abstract screening phase, articles were excluded from further review phases if they met any of the following criteria: not relevant to the outcomes of interest, not relevant to EHRs, nonempirical, and non–peer reviewed. After the application of the exclusion criteria, 80 studies remained for a full-text review. After evaluating the full text of the residual 80 studies, 26 (33%) studies were excluded as they did not address the impact of EHR adoption on the outcomes of interest. Furthermore, 4 additional studies were discovered through manual reference searches and were added to the total, resulting in 58 studies for analysis. A qualitative analysis tool, ATLAS.ti. (version 8.2), was used to categorize and code the final 58 studies.

Results

The findings from the literature review indicated a combination of positive and negative impacts of EHRs on financial and clinical outcomes. Of the 58 studies surveyed for this review of the literature, 5 (9%) reported on the intersection of financial and clinical outcomes. To investigate this intersection further, the category “Value–Intersection of Financial and Clinical Outcomes” was generated. Approximately 80% (4/5) of these studies specified a positive association between EHR adoption and financial and clinical outcomes.

Conclusions

This review of the literature reports on the individual and collective value of EHRs from a financial and clinical outcomes perspective. The collective perspective examined the intersection of financial and clinical outcomes, suggesting a reversal of the current understanding of how IT investments could generate improvements in productivity, and prompted a new question to be asked about whether an increase in productivity could potentially lead to more IT investments.

Development an extended-information success system model (ISSM) based on nurses' point of view for hospital EHRs: a combined framework and questionnaire

Background

Understanding the hospital EHR success rate has great benefits for hospitals. The present study aimed to 1-Propose an extended-ISSM framework and a questionnaire in a systematic manner for EHR evaluation based on nurses’ perspectives, 2-Determine the EHR success rate, and 3-Explore the effective factors contributing to EHR success.

Methods

The proposed framework was developed using ISSM, TAM3, TTF, HOT-FIT, and literature review in seven steps. A self-administrated structured 65-items questionnaire was developed with CVI: 90.27% and CVR: 94.34%. Construct validity was conducted using EFA and CFA. Eleven factors were identified, collectively accounting for 71.4% of the total variance. In the EFA step, 15 questions and two questions in EFA were excluded. Finally, 48 items remained in the framework including dimensions of technology, human, organization, ease of use, usefulness, and net benefits. The overall Cronbach’s alpha value was 93.4%. In addition, the hospital EHR success rate was determined and categorized. In addition, effective factors on EHR success were explored.

Results

In total, 86 nurses participated in the study. On average, the “total hospital EHR success rate” was moderate. The total EHR success rates was ranging from 47.09 to 74.96%. The results of the Kruskal–Wallis test showed that there was a significant relationship between “gender” and “self-efficacy” (p-value: 0.042). A reverse relation between “years of experience using computers” and “training” (p-value: 0.012) was observed. “Years of experience using EHR” as well as “education level” (p-value: 0.001) and “ease of use” had a reverse relationship (p-value: 0.034).

Conclusions

Our findings underscore the EHR success based on nurses’ viewpoint in a developing country. Our results provide an instrument for comparison of EHR success rates in various hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01800-1.

The associations of information system's support and nurses' documentation competence with the detection of documentation-related errors: Results from a nationwide survey

The use of information systems and electronic documentation has become a central part of a nurse's work, and it is expected to increase the quality of documentation and patient safety. However, errors related to documentation have been identified as a significant risk for the quality and safety of care. This study examined whether information system's support for documentation and nurses' documentation competence are associated with how frequently nurses detect documentation-related errors that have caused an adverse event. A nationwide survey was conducted in 2020, and a total of 3610 nurses participated. Results from linear regression analyses showed that high documentation support from the information system and high documentation competence were associated with fewer detected documentation-related errors. Nurses with low documentation support from the system and low documentation competence detected the most errors. The results highlight the need to develop electronic health record functions in a way that they better support accurate documentation. Furthermore, organisations should invest in ensuring the documentation skills of nurses and providing appropriate training.

Evaluating hospital information system according to ISO 9241 part 12

Objectives

Compliance with standards in designing information systems leads to better utilization and ease of use for users. In this study, the compliance of a widely used hospital information system (HIS) with ISO 9241 part 12 was assessed.

Methods

This applied research is a descriptive, cross-sectional study in which the HIS of 8 hospitals affiliated with Kerman University of Medical Sciences was evaluated based on ISO 9241 part 12. Data were collected by using ISO 9241/12 checklist. The data was analyzed in SPSS 16 using descriptive statistics.

Results

The analysis of data showed that the total compliance of the software with the ISO 9241/12 was 72%. The compliance of the software based on different groups of recommendations was 79% with Organization of information, 91% with Graphic objects, and 58% with Coding techniques. Compliance with different subgroups of ISO recommendations ranged from 28% related to “color coding” in coding techniques to 97% related to “General recommendation for graphical objects” in Graphic objects.

Conclusion

According to this study, the design of a widely used HIS has fairly good compliance with the standard but still suffers from some problems. Considering the role of accurate, valid and timely information in management of the hospitals, and the difficulty of system optimization after implementation, it is necessary that software developers follow existing standards when designing health information systems.

Association Between Difficulty with VA Patient-Centered Medical Home Model Components and Provider Emotional Exhaustion and Intent to Remain in Practice

BACKGROUND

The patient-centered medical home (PCMH) model is intended to improve primary care, but evidence of its effects on provider well-being is mixed. Investigating the relationships between specific PCMH components and provider burnout and potential attrition may help improve the efficacy of the care model.

OBJECTIVE

We analyzed provider attitudes toward specific components of PCMH in the Veterans Health Administration (VA) and their relation to emotional exhaustion (EE)-a central component of burnout-and intent to remain in VA primary care.

DESIGN

Logistic regression analysis of a cross-sectional survey.

SUBJECTS

116 providers (physicians; nurse practitioners; physician assistants) in 21 practices between September 2015 and January 2016 in one VA region.

MAIN MEASURES

Outcomes: burnout as measured with the emotional exhaustion (EE) subscale of the Maslach Burnout Inventory and intent to remain in VA primary care for the next 2 years; predictors: difficulties with components of PCMH, demographic characteristics.

KEY RESULTS

Forty percent of providers reported high EE (≥ 27 points) and 63% reported an intent to remain in VA primary care for the next 2 years. Providers reporting high difficultly with PCMH elements were more likely to report high EE, for example, coordinating with specialists (odds ratio [OR] 8.32, 95% confidence interval [CI] 3.58-19.33), responding to EHR alerts (OR 6.88; 95% CI 1.93-24.43), and managing unscheduled visits (OR 7.53, 95% CI 2.01-28.23). Providers who reported high EE were also 87% less likely to intend to remain in VA primary care.

CONCLUSIONS

To reduce EE and turnover in PCMH, primary care providers may need additional support and training to address challenges with specific aspects of the model.

An assessment of the quality of clinical records in elective orthopaedics using the STAR score

BACKGROUND

Litigation claims related to surgery have increased significantly in recent years. Despite the medico-legal importance of clinical records, there have been few published studies describing the quality of medical records in orthopaedic surgery. This study aimed to evaluate the quality of clinical note taking in an elective orthopaedic setting over a 10-year period by comparing medical records from 2003 and 2013.

METHODS

We used the previously validated Surgical Tool for Auditing Records (STAR) on a sample of 20 medical records from each year. We performed statistical analysis to determine if significant differences existed between 2003 and 2013.

RESULTS

There was an overall improvement in the quality of medical records from 76.7% (range 68-82%) in 2003, to 81% (range 72-88%) in 2013 (P value < 0.05). There were significant improvements in the subsequent entry score, from 5.15 to 6.3 (P value < 0.05) and discharge summary score, 6.65 to 7.95 (P value < 0.05). The score for the operative record section decreased from 8.45 to 8.0 (P value < 0.05).

CONCLUSION

The overall standard of medical records in both 2003 and 2013 was high and comparable to other surgical specialties. There was no possible correlation observed between standards of medical records and increasing litigation claims in surgery. Widespread implementation of Electronic Medical Records (EMRs) is likely to have a significant impact on the quality of medical records. Further research is required to determine how the design of EMRs influences how healthcare professionals record data.

A hospital-wide transition from paper to digital problem-oriented clinical notes. A descriptive history and cross-sectional survey of use, usability, and satisfaction

OBJECTIVES

To evaluate the use, usability, and physician satisfaction of a locally developed problem-oriented clinical notes application that replaced paper-based records in a large Dutch university medical center.

METHODS

Using a clinical notes database and an application event log file and a cross-sectional survey of usability, authors retrospectively analyzed system usage for medical specialties, users, and patients over 4 years. A standardized questionnaire measured usability. Authors analyzed the effects of sex, age, professional experience, training hours, and medical specialty on user satisfaction via univariate analysis of variance. Authors also examined the correlation between user satisfaction in relation to users' intensity of use of the application.

RESULTS

In total 1,793 physicians used the application to record progress notes for 219,755 patients. The overall satisfaction score was 3.2 on a scale from 1 (highly dissatisfied) to 5 (highly satisfied). A statistically significant difference occurred in satisfaction by medical specialty, but no statistically significant differences in satisfaction took place by sex, age, professional experience, or training hours. Intensity of system use did not correlate with physician satisfaction.

CONCLUSIONS

By two years after the start of the implementation, all medical specialties utilized the clinical notes application. User satisfaction was neutral (3.2 on a 1-5 scale). Authors believe that the significant factors facilitating this transition mirrored success factors reported by other groups: a generic, consistent, and transparent design of the application; intensive collaboration; continuous monitoring; and an incremental rollout.

Nursing Student Experiences Regarding Safe Use of Electronic Health Records: A Pilot Study of the Safety and Assurance Factors for EHR Resilience Guides

Previous research has linked improper electronic health record configuration and use with adverse patient events. In response to this problem, the US Office of the National Coordinator for Health Information Technology developed the Safety and Assurance Factors for EHR Resilience guides to evaluate electronic health records for optimal use and safety features. During the course of their education, nursing students are exposed to a variety of clinical practice settings and electronic health records. This descriptive study evaluated 108 undergraduate and 51 graduate nursing students' ratings of electronic health record features and safe practices, as well as what they learned from utilizing the computerized provider order entry and clinician communication Safety and Assurance Factors for EHR Resilience guide checklists. More than 80% of the undergraduate and 70% of the graduate students reported that they experienced user problems with electronic health records in the past. More than 50% of the students felt that electronic health records contribute to adverse patient outcomes. Students reported that many of the features assessed were not fully implemented in their electronic health record. These findings highlight areas where electronic health records can be improved to optimize patient safety. The majority of students reported that utilizing the Safety and Assurance Factors for EHR Resilience guides increased their understanding of electronic health record features.

EHR-related medication errors in two ICUs

The objective of this study was to describe the frequency, potential harm, and nature of electronic health record (EHR)-related medication errors in intensive care units (ICUs). Using a secondary data analysis of a large database of medication safety events collected in a study on EHR technology in ICUs, we assessed the EHR relatedness of a total of 1622 potential preventable adverse drug events (ADEs) identified in a sample of 624 patients in 2 ICUs of a medical center. Thirty-four percent of the medication events were found to be EHR related. The EHR-related medication events had greater potential for more serious patient harm and occurred more frequently at the ordering stage as compared to non-EHR-related events. Examples of EHR-related events included orders with omitted information and duplicate orders. The list of EHR-related medication errors can be used by health care delivery organizations to monitor implementation and use of the technology and its impact on patient safety. Health information technology (IT) vendors can use the list to examine whether their technology can mitigate or reduce EHR-related medication errors.

Development of a cognitive framework of patient record summary review in the formative phase of user-centered design

Excellent usability characteristics allow electronic health record (EHR) systems to more effectively support clinicians providing care and contribute to better quality and safety. The Office of the National Coordinator for Health IT (ONC) therefore requires all vendors to follow a User-Centered Design (UCD) process to increase the usability of their products in order to meet certification criteria for the Safety-Enhanced Design part of the Meaningful Use (stage 2) EHR incentive program. This report describes the initial stage of a UCD process in which foundational design concepts were formulated. We designed a functional prototype of an EHR module intended to help clinicians to efficiently complete a summary review of an electronic patient record before an ambulatory visit. Cognitively-based studies were performed and the results used to develop a cognitive framework that subsequently guided design of a prototype. Results showed that clinicians categorized and reasoned with patient data in distinct patterns; they preferred to review relevant history in the assessment and plan section of the most recent note, to search for changes in health and for new episodes of care since the last visit and to look up current-day data such as vital signs. These basic concepts were represented in the design, for instance, by screen division into vertical thirds that had historical content to the left and most recent data to the right. Other characteristics such as visual association of contextual information or direct, one-click access to the assessment and plan section of visit notes were directly informed by our findings and refined in a series of UCD-specific iterative testing. Understanding of tasks and cognitive demands early in the UCD process was critically important for developing a tool optimized for reasoning and workflow preferences of clinicians.

Adoption Factors of the Electronic Health Record: A Systematic Review

Background

The Health Information Technology for Economic and Clinical Health (HITECH) was a significant piece of legislation in America that served as a catalyst for the adoption of health information technology. Following implementation of the HITECH Act, Health Information Technology (HIT) experienced broad adoption of Electronic Health Records (EHR), despite skepticism exhibited by many providers for the transition to an electronic system. A thorough review of EHR adoption facilitator and barriers provides ongoing support for the continuation of EHR implementation across various health care structures, possibly leading to a reduction in associated economic expenditures.

Objective

The purpose of this review is to compile a current and comprehensive list of facilitators and barriers to the adoption of the EHR in the United States.

Methods

Authors searched Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE, 01/01/2012–09/01/2015, core clinical/academic journals, MEDLINE full text, and evaluated only articles germane to our research objective. Team members selected a final list of articles through consensus meetings (n=31). Multiple research team members thoroughly read each article to confirm applicability and study conclusions, thereby increasing validity.

Results

Group members identified common facilitators and barriers associated with the EHR adoption process. In total, 25 adoption facilitators were identified in the literature occurring 109 times; the majority of which were efficiency, hospital size, quality, access to data, perceived value, and ability to transfer information. A total of 23 barriers to adoption were identified in the literature, appearing 95 times; the majority of which were cost, time consuming, perception of uselessness, transition of data, facility location, and implementation issues.

Conclusions

The 25 facilitators and 23 barriers to the adoption of the EHR continue to reveal a preoccupation on cost, despite incentives in the HITECH Act. Limited financial backing and outdated technology were also common barriers frequently mentioned during data review. Future public policy should include incentives commensurate with those in the HITECH Act to maintain strong adoption rates.

The influence of social challenges when implementing information systems in a Swedish health-care organisation

AIM

To describe and obtain a deeper understanding of social challenges and their influence on the implementation process when implementing Information systems in a Swedish health-care organisation.

BACKGROUND

Despite positive effects when implementing Information systems in health-care organisations, there are difficulties in the implementation process. Nurses' experiences of being neglected have been dismissed as reasons for setbacks in implementation.

METHODS

An Institutional Ethnography design was used. A deductive content analysis was made influenced by empirically identified social challenges of power, professional identity and encounters. An abstraction was made of the analysis.

RESULTS

Nineteen nurses at macro, meso and micro levels were interviewed in focus groups. Organisational levels are lost in different ways in how to control the reformation, how to introduce Information systems as reformation strategies and in how to translate new tools and assumptions that do not fit traditional ways of working in shaping professional identities.

CONCLUSION AND IMPLICATION FOR NURSE MANAGEMENT

Different focus may affect the reformation of health-care organisations and implementation and knowledge processes. An implementation climate is needed where the system standards fit the values of the users. Nursing management needs to be visionary, engaged and work with risk factors in order to reform the hierarchical health-care organisation.

How Does Learnability of Primary Care Resident Physicians Increase After Seven Months of Using an Electronic Health Record? A Longitudinal Study

Background

Electronic health records (EHRs) with poor usability present steep learning curves for new resident physicians, who are already overwhelmed in learning a new specialty. This may lead to error-prone use of EHRs in medical practice by new resident physicians.

Objective

The study goal was to determine learnability gaps between expert and novice primary care resident physician groups by comparing performance measures when using EHRs.

Methods

We compared performance measures after two rounds of learnability tests (November 12, 2013 to December 19, 2013; February 12, 2014 to April 22, 2014). In Rounds 1 and 2, 10 novice and 6 expert physicians, and 8 novice and 4 expert physicians participated, respectively. Laboratory-based learnability tests using video analyses were conducted to analyze learnability gaps between novice and expert physicians. Physicians completed 19 tasks, using a think-aloud strategy, based on an artificial but typical patient visit note. We used quantitative performance measures (percent task success, time-on-task, mouse activities), a system usability scale (SUS), and qualitative narrative feedback during the participant debriefing session.

Results

There was a 6-percentage-point increase in novice physicians’ task success rate (Round 1: 92%, 95% CI 87-99; Round 2: 98%, 95% CI 95-100) and a 7-percentage-point increase in expert physicians’ task success rate (Round 1: 90%, 95% CI 83-97; Round 2: 97%, 95% CI 93-100); a 10% decrease in novice physicians’ time-on-task (Round 1: 44s, 95% CI 32-62; Round 2: 40s, 95% CI 27-59) and 21% decrease in expert physicians’ time-on-task (Round 1: 39s, 95% CI 29-51; Round 2: 31s, 95% CI 22-42); a 20% decrease in novice physicians mouse clicks (Round 1: 8 clicks, 95% CI 6-13; Round 2: 7 clicks, 95% CI 4-12) and 39% decrease in expert physicians’ mouse clicks (Round 1: 8 clicks, 95% CI 5-11; Round 2: 3 clicks, 95% CI 1-10); a 14% increase in novice mouse movements (Round 1: 9247 pixels, 95% CI 6404-13,353; Round 2: 7991 pixels, 95% CI 5350-11,936) and 14% decrease in expert physicians’ mouse movements (Round 1: 7325 pixels, 95% CI 5237-10,247; Round 2: 6329 pixels, 95% CI 4299-9317). The SUS measure of overall usability demonstrated only minimal change in the novice group (Round 1: 69, high marginal; Round 2: 68, high marginal) and no change in the expert group (74; high marginal for both rounds).

Conclusions

This study found differences in novice and expert physicians’ performance, demonstrating that physicians’ proficiency increased with EHR experience. Our study may serve as a guideline to improve current EHR training programs. Future directions include identifying usability issues faced by physicians when using EHRs, through a more granular task analysis to recognize subtle usability issues that would otherwise be overlooked.

Electronic Health Record Use a Bitter Pill for Many Physicians

Electronic health record (EHR) adoption among office-based physician practices in the United States has increased significantly in the past decade. However, the challenges of using EHRs have resulted in growing dissatisfaction with the systems among many of these physicians. The purpose of this qualitative multiple-case study was to increase understanding of physician perceptions regarding the value of using EHR technology. Important findings included the belief among physicians that EHR systems need to be more user-friendly and adaptable to individual clinic workflow preferences, physician beliefs that lack of interoperability among EHRs is a major barrier to meaningful use of the systems, and physician beliefs that EHR use does not improve the quality of care provided to patients. These findings suggest that although government initiatives to encourage EHR adoption among office-based physician practices have produced positive results, additional support may be required in the future to maintain this momentum.

Impact of Implementing an Electronic Health Record on Surgical Resident Work Flow, Duty Hours, and Operative Experience

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means ( P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation ( P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation ( P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.

Evaluating the Reliability of EHR-Generated Clinical Outcomes Reports: A Case Study

Introduction:

Quality incentive programs, such as Meaningful Use, operate under the assumption that clinical quality measures can be reliably extracted from EHRs. Safety Net providers, particularly Federally Qualified Health Centers and Look-Alikes, tend to be high adopters of EHRs; however, recent reports have shown that only about 9% of FQHCs and Look-Alikes were demonstrating meaningful use as of 2013. Our experience working with the Crescent City Beacon Community (CCBC) found that many health centers relied on chart audits to report quality measures as opposed to electronically generating reports directly from their EHRs due to distrust in the data. This paper describes a step-by-step process for improving the reliability of data extracted from EHRs to increase reliability of quality measure reports, to support quality improvement, and to achieve alignment with national clinical quality reporting requirements.

Background:

Lack of standardization in data capture and reporting within EHRs drives distrust in EHR-reported data. Practices or communities attempting to achieve standardization may look to CCBC’s experience for guidance on where to start and the level of resources required in order to execute a data standardization project. During the time of this data standardization project, CCBC was launching an HIE. Lack of trust in EHR data was a driver for distrust in the HIE data.

Methods:

We present a case study where a five-step process was used to harmonize measures, reduce data errors, and increase trust in EHR clinical outcomes reports among a community of Safety Net providers using a common EHR. Primary outcomes were the incidence of reporting errors and the potential effect of error types on quality measure percentages. The activities and level of resources required to achieve these results were also documented by the CCBC program.

Findings:

Implementation of a community-wide data reporting project resulted in measure harmonization, reduced reporting burden, and error reduction in EHR-generated clinical outcomes reporting across participating clinics over a nine-month period. Increased accuracy of clinical outcomes reports provided physicians and clinical care teams with better information to guide their decision-making around quality improvement planning.

Discussion:

A number of challenges exist to achieving reliable population level quality reporting from EHRs at the practice, vendor, and community levels. Our experience demonstrates that quality measure reporting from EHRs is not a straightforward process, and it requires time and close collaboration between clinics and vendors to improve reliability of reports. Our experience found that practices valued the opportunity and step-wise process to validate their data locally (out of their EHRs) prior to reporting out of the HIE.

Conclusion and Next Steps:

Communities can achieve higher levels of confidence in quality measure reporting at the population level by establishing collaborative user groups that work with EHR vendors as partners and use technical assistance to build relationships and trust in EHR-generated reports. While this paper describes the first phase of our work around improving standardization and reliability of EHR reports, vendors should continue to explore modifications for improving data capture (at the front-end) via standardized data entry templates.

Electronic medical records and quality of cancer care

The implementation of electronic medical records (EMR) systems was mandated by the U.S. federal government in large part due to research indicating that difficulty accessing clinical data was one of the most common causes of preventable deaths. Several assumptions were implicit in this mandate, including the assumption that the implementation of EMR would indeed improve clinicians' access to clinical data, that implementation of EMR would pose little to no risk to patients, and that the clinical benefit of improved access to clinical data would outweigh any risks that might arise. As detailed in this review, both formal research and extensive experiential observation have called all three assumptions into question. Specifically, as detailed below, there is clear evidence that EMR systems are associated with multiple specific risks to patients, whereas few, if any, scientifically rigorous outcomes-based studies have demonstrated that the potential benefits of EMR outweigh the known risks. In addition, there is currently little to no scientifically rigorous evidence that EMR systems constitute a cost-effective methodology for improving patient outcomes.

Impact of electronic health record systems on information integrity: quality and safety implications

While the adoption of electronic health record (EHR) systems promises a number of substantial benefits, including better care and decreased healthcare costs, serious unintended consequences from the implementation of these systems have emerged. Poor EHR system design and improper use can cause EHR-related errors that jeopardize the integrity of the information in the EHR, leading to errors that endanger patient safety or decrease the quality of care. These unintended consequences also may increase fraud and abuse and can have serious legal implications. This literature review examines the impact of unintended consequences of the use of EHR systems on the quality of care and proposed solutions to address EHR-related errors. This analysis of the literature on EHR risks is intended to serve as an impetus for further research on the prevalence of these risks, their impact on quality and safety of patient care, and strategies for reducing them.

A qualitative study of the activities performed by people involved in clinical decision support: recommended practices for success

Objective

To describe the activities performed by people involved in clinical decision support (CDS) at leading sites.

Materials and methods

We conducted ethnographic observations at seven diverse sites with a history of excellence in CDS using the Rapid Assessment Process and analyzed the data using a series of card sorts, informed by Linstone's Multiple Perspectives Model.

Results

We identified 18 activities and grouped them into four areas. Area 1: Fostering relationships across the organization, with activities (a) training and support, (b) visibility/presence on the floor, (c) liaising between people, (d) administration and leadership, (e) project management, (f) cheerleading/buy-in/sponsorship, (g) preparing for CDS implementation. Area 2: Assembling the system with activities (a) providing technical support, (b) CDS content development, (c) purchasing products from vendors (d) knowledge management, (e) system integration. Area 3: Using CDS to achieve the organization's goals with activities (a) reporting, (b) requirements-gathering/specifications, (c) monitoring CDS, (d) linking CDS to goals, (e) managing data. Area 4: Participation in external policy and standards activities (this area consists of only a single activity). We also identified a set of recommendations associated with these 18 activities.

Discussion

All 18 activities we identified were performed at all sites, although the way they were organized into roles differed substantially. We consider these activities critical to the success of a CDS program.

Conclusions

A series of activities are performed by sites strong in CDS, and sites adopting CDS should ensure they incorporate these activities into their efforts.