Electronic Health Record: What Do You Expect From Them?* David Bracco, MD, PhD, FCCM, FRCS(C) Department of Anesthesia, Faculty of Medicine McGill University Montreal, QC, Canada Fabrice Labeau, PhD Department of Electrical and Computer Engineering Faculty of Engineering McGill University Montreal, QC, Canada

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lectronic health records (EHRs) have paralleled the evolution of computing power. Thirty years ago, these were mostly administrative databases, managing almost exclusively health-associated administrative data Then several other aspects of health care such as laboratory or pharmacy switched from paper to electronic. During the past 15 years, radiology went electronic replacing tons of films by numerical picture archiving and communication systems data and bedside charting was transformed to electronic clinical files.

EHR-ASSOCIATED IATROGENESIS Deployment of EHR system has been associated with a number of promises, including lower cost of care, streamlined care process, and improved communication. Clinicians expect EHR to support delivery of high-quality critical care, including storing comprehensive data, supporting clinical decision support, streamlining communication, and reducing/trapping medical errors. The potential benefits have been undermined by serious unintended and unplanned consequences of EHR: poor electronic chart design or poor graphical interface or improper use has been associated with unreliable information, to errors and patient safety issues. EHR components have been associated with increased medication errors (1) and even with an increase in mortality (odds ratio, 3.28) in a pediatric unit (2). These risks, sometime referred as “e-iatrogenesis”, can rapidly offset the potential benefits of EHR, thus leading to conflictual

*See also p. 1276. Key Words: clinical decision systems; e-iatrogenesis; electronic health records Dr. Labeau is employed by McGill University and received support for travel from the Institute of Electrical and Electronics Engineers (several committee meetings, reimbursement of travel costs). Dr. Labeau and his institution have patents with Huawei. His institution received grant support from the Natural Science and Engineering Research Council, Canada, and from Fond Quebecois de Recherche, Hydro-Quebec. Dr. Bracco disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000001007

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publications. One crucial issue is representation of a task by the end user clinician and the software designer: When these are not aligned, the resulting action may worsen quality of care and patient outcome. This is nicely shown in the review by Chaudhry et al (3) were only four institutions with internally developed software, ie, tool starting from the local way of delivering care, showed a positive effect on outcome. Several root causes may lead to EHR flaws: incomplete specifications, classical programmatic bugs, working adequately in one settings, and poorly in other or interfering with usual clinical care introducing. In this context, it is not surprising that the metaanalysis by Thompson et al (4) including all types of EHRs in the ICU fails to show a beneficial effect on morality or length of stay. One has to investigate the causes of this and build the next-generation EHR, avoiding the previous errors. In a recent analysis of 100 EHR-related patient safety concerns from the Veteran administration, 74 were attributed to unsafe technology and 25 to unsafe use of technology. Two thirds involved multidimensional problems including human factors (workflow, policies, and training) versus technical factors (software and hardware)(5). When designed, integrated, or used inappropriately, EHRs add a useless layer of complexity to an already complex healthcare delivery system, despite the fact that, in humancomputer interaction, the bother caused by the intervention of new technological tools is now well understood and has been recently studied specifically in the healthcare delivery setting. This added complexity leads, for example, to dosing errors, delayed interventions due to poor human-computer interaction (eg, epidural hematoma CT scan report not picked up by clinician). Safety of a process can be improved by limiting the number of steps and/or by improving the safety of each step. A multistep system where MD order a test on the computer, nurse pick it up through one transaction, and print the order request through another transaction is not operational, cumbersome, and time wasting for a busy postcardiac surgery ICU or trauma resuscitation room. Classically, EHR are designed as message-handling (information) systems, a transaction-based architecture. These systems should evolve into patient-centered systems, meeting the needs from the patients and healthcare teams.

HETEROGENEITY OF EHRs The various EHRs system deployed across ICU worldwide are very heterogeneous as reported by Chaudhry et al (3). Despite efforts to go completely electronic, the “devil” in the system is the printer: there are numerous hybrid paper/electronic handout and documents in use (6). Clinician round with paper handouts adds some notes at the bedside and then returns to update the electronic chart from the desk at the end of the June 2015 • Volume 43 • Number 6

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Editorials

round. Multiples systems, with multiple login architectures, are deployed: even in a single institution, information is spread across PACS, EHR, dedicated ICU, or emergency department charting systems, anesthesia charting systems, laboratory systems, etc. Same information, for example, patient allergies— has to be entered in various system—in the mainframe EHR, the pharmacy system, the anesthesia system, etc. Recently, there has been a strong signal for user-centered software, with all the information coded to the highest level and centralized in a single repository. Despite this, legacy systems are still installed in numerous healthcare facilities. The inability of vendors to provide human factor-optimized interfaces and systems that incorporate legacy investment, legacy development tools rather than providing side-by-side solutions has led to bad experiences in many ICUs. In addition, after investing significant funds and time in acquiring and implementing a system in a healthcare organization and discovering the flaws and limitations of the system, one is more likely to retain a bad system rather than re-invest to replace it (7).

DATA QUALITY IN EHR SYSTEMS Data in EHRs are in numerous formats and configurations. This ranges from scanned paper to “free text” to International Classification of Diseases–coded diagnosis. A scanned handwritten anesthesia chart or consult note does not allow to search for lowest intraoperative blood pressure, for example. A free text radiological report showing grade 3 liver laceration will not allow to search for all liver lacerations in my trauma population. Data have to be recoded as S36.115: moderate laceration of the liver. The particular problem of follow-up medical notes should be addressed: several studies have shown the “copy/paste” syndrome with unnecessarily long note, loss of track of the first description and degradation of the quality of data down the road (8). In addition, little research has been devoted to the concepts and definitions of quality of data in EHR (9), (10). This seriously limits the use of EHR data for performance appraisal (11), clinical research (12), and clinical decision making.

HOW CAN EHRs SUPPORT BETTER CARE? Classically, healthcare structures, process of care, and outcome are linked: the better the structure, the better the process and outcome. For example, implementation of comprehensive regional trauma systems has decreased mortality by 15–20% by itself. Clinicians expect health IT to help delivery of high quality by storing comprehensive health data, assisting in clinical decision support, streamlining communication. They expect that this “improved” structure and way of delivering care will be linked with improved outcome. There is still a huge gap between the expectations of the clinicians and the promises of the vendors. The improved (and expensive) structure is not automatically linked to a better way of delivering care or outcome. To reduce the gap, get the most benefits from EHR and improve patient outcome, all stakeholders should focus on simple principles (13). First, risks of EHR errors must Critical Care Medicine

be seriously quantified, root causes searched, and an universal analysis set up. Second, information in EHR must be reliable, verified, and coded appropriately. Scanned handwritten (often illegible) progress notes or consultant notes, free texts in radiology reports are not useful in expert clinical decision systems or quality control research. Third, systems deployed in a single institution should be integrated into a wall-to-wall “flight management system.” The amount of information generated by a critical care patient is huge: An average of 12,000 data points are generated per 24 hours per patient with “an abundance of unused data” (14), and information overload is presented in standard interfaces (15). Screen interfaces become more and more crowded with menu bars, sliders, labels, etc, leaving less and less space to the core of information. This is an industry-wide trend: by analogy, various versions of Microsoft Word have used more and more space to menu bars, toolbars, status bars, thumbnails, and shrinking the effective text/data area. Human factors design must become the key driver of interface design for EHR data entry and consultation; the software industry has been used to providing the healthcare systems with very good data manipulation and storage tools, but with poor data production and consumption endpoints (for instance, data entry in early administrative systems was performed by dedicated staff); it is important that this industry moves to designs that are centered on data endpoints because these endpoints are the key drivers of acceptance of any EHR application. Other key acceptance factors include speed, simplicity of process, and usability (16). Several aspects of EHRs have to be improved in the future: first, there is a need for public error reporting and common error taxonomy and classification (17). Second, the governance of EHR and vendors has to strengthen. Third, the business scope of EHR and vendors has to change: from translating to electronic a historically paper chart (the what business), they have to move to the features (the how business) and the why are we doing EHRs.

REFERENCES

1. Koppel R, Metlay JP, Cohen A, et al: Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293:1197–1203 2. Han YY, Carcillo JA, Venkataraman ST, et al: Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 2005; 116:1506–1512 3. Chaudhry B, Wang J, Wu S, et al: Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006; 144:742–752 4. Thompson G, O’Horo JC; Pickering BW, et al: Impact of the Electronic Medical Record on Mortality, Length of Stay, and Cost in the Hospital and ICU: A Systematic Review and Metaanalysis. Crit Care Med 2015; 43:1276–1282 5. Meeks DW, Smith MW, Taylor L, et al: An analysis of electronic health record-related patient safety concerns. J Am Med Inform Assoc 2014; 21:1053–1059 6. Collins SA, Mamykina L, Jordan D, et al: In search of common ground in handoff documentation in an Intensive Care Unit. J Biomed Inform 2012; 45:307–315 7. Slight SP, Quinn C, Avery AJ, et al: A qualitative study identifying the cost categories associated with electronic health record www.ccmjournal.org

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Editorials implementation in the UK. J Am Med Inform Assoc 2014; 21:e226–e231 8. Weis JM, Levy PC: Copy, paste, and cloned notes in electronic health records: Prevalence, benefits, risks, and best practice recommendations. Chest 2014; 145:632–638 9. Weiskopf NG, Weng C: Methods and dimensions of electronic health record data quality assessment: Enabling reuse for clinical research. J Am Med Inform Assoc 2013; 20:144–151 10. Chan KS, Fowles JB, Weiner JP: Review: Electronic health records and the reliability and validity of quality measures: A review of the literature. Med Care Res Rev 2010; 67:503–527 11. Parsons A, McCullough C, Wang J, et al: Validity of electronic health record-derived quality measurement for performance monitoring. J Am Med Inform Assoc 2012; 19:604–609 12. Bayley KB, Belnap T, Savitz L, et al: Challenges in using electronic health record data for CER: Experience of 4 learning organizations and solutions applied. Med Care 2013; 51:S80–S86

13. Middleton B, Bloomrosen M, Dente MA, et al; American Medical Informatics Association: Enhancing patient safety and quality of care by improving the usability of electronic health record systems: Recommendations from AMIA. J Am Med Inform Assoc 2013; 20:e2–e8 14. Pickering BW, Gajic O, Ahmed A, et al: Data utilization for medical decision making at the time of patient admission to ICU. Crit Care Med 2013; 41:1502–1510 15. Ahmed A, Chandra S, Herasevich V, et al: The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance. Crit Care Med 2011; 39:1626–1634 16. Bates DW, Kuperman GJ, Wang S, et al: Ten commandments for effective clinical decision support: Making the practice of evidencebased medicine a reality. J Am Med Inform Assoc 2003; 10:523–530 17. Bowman S: Impact of electronic health record systems on information integrity: Quality and safety implications. Perspect Health Inf Manag 2013; 10:1c

Middle East Respiratory Syndrome: The Need for Better Evidence in Severe Respiratory Viral Infections* Hani Abo-Leyah, MBChB James D. Chalmers, MD Department of Respiratory Medicine College of Medicine University of Dundee Dundee, United Kingdom

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igh contagious and deadly viruses are not new but have rarely had such a high profile. The Ebola epidemic in West Africa demonstrates the potential impact of a highly contagious virus with the capacity to spread beyond the available means to contain it. At the time of writing this outbreak continues, with now more than 14,000 laboratory confirmed cases (as of February 25, 2015) (1). Respiratory viruses also have the capacity to be rapidly transmitted and deadly. The 1918 influenza pandemic (“Spanish flu”) is reported to have killed 20–40 million people (2). The nature of genetic changes in influenza viruses, in particular, makes global pandemics of respiratory viral infections a matter of “when” rather than “if”. Public awareness of the potential for global transmission of lethal respiratory viruses is high following the 2009/2010 pandemic of H1N1 influenza, and high *See also p. 1283. Key Words: Middle East respiratory syndrome; pandemic; pneumonia; transmission; virus Dr. Chalmers consulted for Bayer HealthCare, Cempra Pharmaceuticals, and Astrazeneca. His institution received grant support from Bayer HealthCare, Aradigm Corporation, and Astrazeneca. Dr. Abo-Leyah disclosed that he does not have any potential conflicts of interest. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000001008

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profile reporting of respiratory virus outbreaks, such as severe acute respiratory syndrome (SARS) and avian influenza A (3–5). Against this backdrop, this issue of Critical Care Medicine features a comprehensive update from Dr. Alsolamy (6) on the epidemiology and management to date of Middle East Respiratory Syndrome coronavirus (MERS-CoV). As of January 30, 2015, there have been 956 laboratory-confirmed cases of MERS-CoV infection with a case fatality rate of 36.7% according to the World Health Organization (7). Primary infections have all been reported from countries in the Arabian peninsula, with evidence of worldwide transmission of cases through travel (Table 1). The disease can vary in severity from asymptomatic infection, detected on contact screening, to rapidly progressive pneumonia and respiratory failure (6, 7). It should be suspected in any individual with an acute respiratory illness within 14 days of travel to Arabian Peninsula (7). Alsolamy (6) highlights the role of detection bias in the early overestimation of the high case-fatality ratio reported with MERS-CoV; nevertheless, it is clear that it can be transmitted from person to person and has the potential to be rapidly fatal. A review of recent cases in Jeddah, Saudi Arabia, has identified that a majority of new infections during 2014 were either in healthcare workers or appeared likely to have been acquired from healthcare-associated transmission (8). Supportive management of viral infections remains the dominant approach partly because of the lack of effective antiviral therapeutics. Previous experience with SARS, in particular, has influenced the treatment options used by centers in Saudi Arabia dealing with MERS. Alsolamy summarizes the available literature concerning ribavirin and interferon α therapy in MERS (6). Omrani et al (9) reported a retrospective June 2015 • Volume 43 • Number 6

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Electronic health record: what do you expect from them?

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