A Policy Agenda to Address New Unintended Adverse Consequences of EHRs

flying cadeuciiIn large part due to the $35 billion, Health Information Technology for Economic and Clinical Health (HITECH) Act incentives more than 80% of acute care hospitals now use EHRs, from under 10% just 7 years ago. Despite considerable progress, we have not achieved all that was originally envisioned from this transformation and there have been numerous unexpected adverse consequences (UACs), i.e. unpredictable, emergent problems associated with health IT implementation, use and maintenance. In 2006, we described a set of UACs associated with use of computer-based provider order entry (CPOE) (see Table 1).  Many of these originally identified UACs have not been completely addressed or alleviated, and some have evolved over time (e.g., more/new work, overdependence on technology, and workflow issues).  Additionally, new UACs not just related to CPOE but to all aspects of EHR use have emerged over the last decade.  We describe six new categories of UACs in this blog and then conclude with three concrete policy recommendations to achieve the promised, transformative effects of health IT. 

1. Complete clinical information unavailable at the point of care

Adoption of EHRs was supposed to stimulate a tremendous increase in availability of patients’ clinical data, anytime, anywhere. This ubiquitous increase in data availability depended heavily on the assumption that once clinical data were routinely maintained in a computable format, they could seamlessly be transmitted, integrated, and displayed between health care systems’ EHRs, regardless of differences in the developer of the EHR. However, complete clinical information on all patients is not yet available everywhere it is needed.

2. Lack of innovations to improve system usability leads to frustrating user experiences

Although EHR usability has improved considerably since the days of hard-wired, keyboard-based, VT100 terminals connected to a mainframe computer (see figure 1), very little has changed since the current mouse-based, point and click, graphical user interfaces were introduced 15 years ago. 

Figure 1. A Digital Equipment Corporation (DEC) VT100 terminal. (from: https://en.wikipedia.org/wiki/User_interface)

3. Inadvertent disclosure of large amounts of patient-specific information

Health care is increasingly a victim of a large number of patient privacy breaches. Some of these are the result of external bad actors trying to take advantage of the increased monetary value of personally-identifiable health-related data, such as the breach of over 78.8 million patient files at Anthem. Others are the result of health care organizations’ failure to take the necessary precautions to protect their systems.

4. Increased focus on computer-based quality measurement negatively affects clinical workflows and patient-provider interactions

The move from fee-for-service to pay-for-performance payment models in health care has given rise to more EHR-based clinical quality measurement. This push for quality measurement has necessitated an increased need for capturing complete, accurate, structured data that can easily be extracted, aggregated, and reported to administrators, quality oversight organizations, and payers – both public and private. These requirements for the entry of more structured data have resulted in increases in clinician work load.

5. Information overload from marginally useful computer-generated data

As the breadth and depth of computer usage to record, store, display, and transmit clinical and administrative information have increased, so has the amount of information that clinicians are required to review and act upon.  The capability for patients to generate, capture, and transmit information about various physiological (e.g., blood glucose, heart rate, or blood pressure) or physical (e.g., number of steps walked or hours slept) processes further exacerbates the amount of information potentially available to clinicians.

6. Decline in the Development and Use of Internally-developed EHRs

Over the last decade, the number of EHRs developed and maintained by academic researchers for their teaching facilities, or entrepreneurs for their small practices, has declined precipitously as large academic health centers increasingly adopted commercial EHRs and acquired small practices. Many of the previously developed innovations are not being translated to the new EHR products.   

Policy Recommendations

Each of the UACs identified above poses significant challenges to EHR developers and users and a new policy agenda is needed to mitigate these problems.

Fund Research Dedicated to Measurement of EHR-related Safety

Measurement is often considered an essential first step to improvement. Addressing the wide safety gaps in EHR usability, interoperability, information management, and data security requires valid and reliable measurements to help assess whether newly implemented features and functions are actually improving patient care. A new National Quality Forum (NQF) report provides guidance on how to measure the safety and safe use of health IT, prioritizes risk areas and builds a strong scientific foundation to advance measurement science in this area. However, without additional research and development, this measurement agenda will not move forward.  For example, the NQF recently endorsed a safety measure focused on wrong patient errors which was developed through a substantial amount of research and validation efforts before it was considered ready.  Few funding agencies however fund this type of research.  The budget for Agency for Healthcare Research and Quality (AHRQ) must be increased in order to do this and related safety work that will be needed to develop and test interventions once these measurements are widely adopted.

Develop Models for Better Collaboration between EHR Vendors and Academic Informaticians

Currently, there is little collaboration between academic informaticians who often evaluate and recommend improvements to the EHR and EHR vendors. To ensure progress, we need to develop new models of collaboration where a) EHR vendors address both problems and recommendations emerging from the work done by the academic informatics research community and b) EHR vendors inform the research community of new problems researchers should address.  Currently, many contractual barriers exist, which taken together make important research on usability, interoperability, and security difficult if not impossible. For example, many EHR vendors restrict sharing of screen shots of their systems, which has had the effect of stifling EHR usability testing and research. Recommendations on how to address some of these issues now need to be operationalized.

Create a National EHR Safety Center

As we have previously described in great detail, creation of a National EHR Safety Center is critical for the collection, investigation, and analysis of EHR-related errors. Without such a center, we will never know the true extent of what are currently perceived to be idiosyncratic EHR problems due to local configuration, implementation, or use. With access to more data, we may be able to identify commonalities in specific error-prone events, workflow processes, hardware configurations, or interactions between disparate clinical computing applications and begin to develop scalable solutions to address them.

The opportunities to leverage health IT to impact health and health care have never been greater.  While the health IT revolution has had a tremendous positive impact, new UACs have emerged. We must re-focus our efforts to address UACs and facilitate a safe, effective and efficient EHR infrastructure in order to do this. These policy recommendations are a start. 


<em>Dean Sittig is with the University of Texas Health Science Center at Houston, Adam Wright is with Harvard Medical School, Joan Ash is with Oregon Health & Science University, Hardeep Singh is with Baylor College of Medicine. </em>

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10 replies »

  1. We don’t need a new office to deal with a mutant office. We need them all to be closed. We need the regulations, relationships, advisers and migraines to be defunded and ended. They are the mutant child of leftist do-gooderism and crony capitalism, EPIC and the Obama campaign go way back–see below. That is what spurred the growth of the abomination. You are naive if you think this occurred in a greenhouse of good intentions.
    What we need are indictments and prison terms for all the players involved. I can dream, right? At the very least they need to be fired. I hope some people reading this will start to question the why’s and wherefore’s.




  2. It has to be just a matter of information theory, doesn’t it? There are lots of ways to record and transmit and process and receive information; and the EHR is just one of them. E.g. there are lots of bits of information that are missing in an EHR….say, vs the handwritten chart: the size of the written words and letters; their placement on the page; the intensity of the writing; the underlining; the use of colored ink or pencils.

    The handwritten chart was also a sort of scrapbook. The patient might bring specimens such as a passed renal stone or an article describing some symptom–that mirrored his symptom–that he saw in the newspaper. He might bring in a photograph of yesterday’s rash.

    Anyway, we need a broad information theory approach as to where to go next in health care. It is not just the total bits of information gathered, stored and disseminated. It is a matter of the efficient number of bits and the efficient way it is presented and maximizing the ultimate beneficence of these data bits for the patient. And all these efficient ways to manage information are probably somewhat different for each provider. The nurse perhaps needs a different format and different bits than the doctor or the x-ray techologist. Some information might be more efficient digitally and some in handwriting and some in audio and some in graphics and some in cryptic arcane codes or symbols.

    And styles count too. You don’t want to repeat too much. You don”t want to bore the reader. You don’t want to distract the doctor (by giving him or asking for non-relevant bits) from his need for certain other information at that time. The style needed for interoperability uses could be quite different from the style the doctor needs for his own records or the style to be sent to the patient who wants to see his records.

    We shouldn’t fall in love with any information architecture yet….it is too early.

  3. Institutional EHRs are an infrastructure commodity, like plumbing, not a clinical technology that has been hyped and mandated into a role it cannot sustain. Regulatory policy must shift the industry away from information blocking and to clear outcomes such as:

    “Does the EHR allow independent decision support at the point of care for both physicians and patients?”


  4. The only EHR policy change needed is this: repeal the mandate to adopt EHR’s.
    Then future investment in new EHRs or upgrades would be happen when EHR providers come up with systems that really improve quality of care and efficiency of care without unintended consequences…..let docs and hospital systems decide and bear the risk if it doesn’t work. Instead, they essentially mandated all health systems adopt a technology that just wasn’t ready.

    The original mistake was mandating adoption of a new technology that was not ready…..and gave EPIC a huge advantage…..creating a disincentive for new players to come up with a better system since health systems were committed to their sunk dollars.

    It was as if the federal govt. had mandated purchase if cell phones in the 1990’s……remember Motorola Star Tac was the coolest thing? If that had happened, the iPhone would not have been developed….or at least much delayed….since everyone had committed to Motorola.

    • You are right. These things cannot be mandated. They need to grow organically so that the physician’s experience learned through study as well as trial and error can be incorporated.

      • If I am not mistaken, nearly all medical journals and reference books are organized in two or three columns with each line containing 7-9 words. A person learns to scan these texts looking for certain phrases as the basis for a learning process. None of the ehrs are organized to support this tradition.

        By the way, does anyone remember the original Rand Study that the Institute of Medicine commissioned to study the use of computers for healthcare? I am aware that they obtained outside financial support for the report. Tell me then, who paid for it?

    • How can you maintain a comprehensive care plan without an automatically configured flowsheet? As a reflection of our time, the the spell checker of this Blog doesn’t recognize the word [ flowsheet ] !

    • I agree. We were forced to convert to a technology that wasn’t even close to being ready for prime time.

      Now, practices are too heavily invested in technology that doesn’t work for them to see their way out of the situation they’re in.

      To quote myself…

      “I know how things could get better:

      Every quarter, impose a rebate of 25% of each EMR purchase price, paid by the vendor to each practice that isn’t able to use their product as promised. That would place the problem where it belongs, instead of with the hapless consumer. I think that would speed up product improvement and tech support a whole lot.

      Compare today’s struggle to achieve Meaningful Use with what happened with faulty General Motors ignition switches, exploding Takata airbags and polluting Volkswagen diesels. Nobody blamed the consumer for such problems.

      Why, then, are medical providers held responsible for having bought, under pressure, less than functional electronic medical records?

      Make the EMR vendors attest to Meaningful Use instead of us!”


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