The use of electronic health records (EHR) in healthcare increases daily, and so does the importance of understanding the safest and most efficient methods for their utilization. One seemingly simple feature of EHRs under scrutiny pertains to the number of records that should be allowed open by a clinician at the same time, and whether multiple open records would lead to greater error in documentation and care.
Both the Office of the National Coordinator for Health IT (ONC) and the Joint Commission recommended that clinicians should be limited to one open record at a time. Jason Adelman, who holds dual Columbia appointments in both Medicine and the Department of Biomedical Informatics (DBMI), used his own Wrong-Patient Retract-and-Reorder (RAR) Measure to study this question in a recent randomized clinical trial.
His findings, which were shared in the May 14 issue of JAMA, did not line up with the ONC/Joint Commission recommendations. There was no significant difference in errors between clinicians randomly assigned to a group restricted to one open medical record and those assigned to a group allowed to open as many as four at a time.
Other findings did present questions of their own. Both Adelman and Bob Wachter, chairman of the UCSF Department of Medicine, added insight in the issue of JAMA.
The Agency for Healthcare Research and Quality (AHRQ) funded an earlier Adelman survey that found approximately 40% of hospitals allowed the maximum number of records open for each system, while another 40% limited their clinicians to one open record at a time. Both gave reasonable explanations to their logic, ranging from allowing doctors to multitask to being concerned about wrong-patient errors with multiple open records.
Given that the ONC and Joint Commission recommendations were based on expert opinion, Adelman believed that evidence was critical to study both efficiency and safety in this area of healthcare.
“We wanted to answer the question can doctors safely open multiple records,” said Adelman, whose RAR measure was used with a new EHR system at all sites of a clinical trial. This allowed Adelman and colleagues to track the number of times one or more orders was placed for a patient that were retracted (cancelled) by the same clinician within 10 minutes, and then reordered by the same clinician for a different patient within the next 10 minutes.
What The Study Found
More than 3,300 clinicians were randomized into two groups over a 19-month time period. One group was limited to one open health record (restricted), while the other group could open as many as four at any given time (unrestricted). Nearly 4.49 million order sessions were completed during the study period, and the difference in error rate between the restricted and unrestricted groups was 2.7 per 100,000 orders sessions.
While there was no significant difference between groups overall, there also was no difference broken down by practice settings (emergency department, inpatient, outpatient).
The unrestricted group generated findings that did require greater consideration. The rate of errors generally increased when multiple records were opened, and the majority of orders (66.2%) were placed with one open record at a time, even though clinicians were allowed to open up to four at a time.
“Why are the error numbers going up when you have more records open when we know from the randomized trial that there was no difference?” Adelman said. “The general thinking is that this is what we call ‘confounding,’ and that the problem really isn’t having multiple records open. The problem is that this is often a sign of multitasking. Working on multiple patients at once is the problem, not having multiple records open.”
Why It Matters
As EHRs become central to clinicians’ workflows, further study is needed to determine how to balance efficiency with patient safety.
Wachter shared this opinion in his May 14 JAMA editorial:
“While there was evidence suggesting increasing errors with more open records, the comparison with the restricted group suggests that order-error rates were in fact lowest when clinicians exercised the choice of opening 1 record at a time, rather than being restricted to opening only 1 record. Additional research is necessary to identify modifiable factors contributing to this error rate, including clinician workload. Policies that restrict open records should not be enacted without understanding the broad effects of such policies on safety, throughput, and clinician satisfaction.”
Adelman compared earlier calls for restricted EHR usage to a parachute (do we really need to study if parachutes are useful when jumping from a plane?), and this study shows the importance of evaluating EHR usage instead of simply instituting a recommendation based on reason, not data.