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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