American College of Physicians: Internal Medicine — Doctors for Adults ®


How EMR software can help prevent medical mistakes

Deadly drug interactions are just one type of error that electronic information systems can flag in your practice

From the September ACP Observer, copyright 2004 by the American College of Physicians.

By Jerome H. Carter, FACP

Since the Institute of Medicine released its seminal study estimating that up to 98,000 Americans die each year from preventable errors, patient safety has occupied an important place in the national debate about health care. More recent reports, like the one published earlier this summer by the Colorado-based consulting firm HealthGrades putting that figure closer to 195,000 deaths, have only added to the scrutiny—and put pressure on physicians to identify solutions.

Electronic medical record (EMR) software isn't a cure-all that will eradicate errors, but it can help reduce the odds that you and your colleagues will make a mistake. While it's true that certain types of errors require "intelligent" or nuanced systems that are not always available, many commercial systems can help you eliminate the most frequent and lethal mistakes.

In this article, I'll focus on how internists can reduce three types of errors: those related to prescription drugs, to preventive care, and to tests and procedures.

Drug prescribing problems

The most common—and deadly—treatment errors occur when physicians make mistakes prescribing medicines. Clinicians are most likely to make the following errors:

  • Prescribe drugs that interact with other medicines the patient is already taking, or with foods the patient commonly eats.

  • Give patients a drug they are allergic to or have already experienced an adverse event with.

  • Fail to recognize a critical side effect.

  • Give an incorrect dose or use an inappropriate frequency.

Detecting all possible drug interactions every time you change or prescribe a new medicine is not practical for busy practitioners still using paper records.

It is often difficult, for example, to recognize when patients who are taking multiple drugs and present with new complaints may actually be suffering from an unrecognized drug interaction, not a new disease or ailment. The widespread use of herbal supplements only increases your chances of an interaction.

In many instances, only an EMR can effectively deal with this problem. While drug allergies can occur with a specific drug, an entire class of drugs or related classes, patients often provide allergy information only in terms of a specific drug. As a result, physicians are left to detect class-level allergies.

This lack of systems support forces physicians to quickly recall complex drug information that can change from day to day. Complicating matters, adverse events may be disguised in the medical record as diagnoses, not adverse reactions.

Physicians may not link common reactions like headache or nausea to a drug interaction, and even serious events such as anemia may be attributed to other causes. The same is true of side effects. Many physicians rely solely on their memory to write prescriptions and then handle the problems that inevitably arise, including incorrect dosage or frequency, or improper combination with foods.

What EMR features can help prevent medication errors? Important features include automatic drug-drug/drug-food interaction checks and allergy checks that catalogue drugs and all associated classes.

Other features that can help you eliminate drug errors include:

  • ad-hoc formulary search capability that allows you to search the contents of a medical record system's drug database by side effect and adverse event;

  • a formulary module that presents standard drug dosages and information about the administration of drugs;

  • a database of drug monographs; and

  • patient education information, such as handouts, that describe common side effects and adverse events, as well as give patients dosing and administration information.

Preventive services

When it comes to preventive care, EMR software can help you avoid many of the more subtle errors that plague offices and hospitals alike. Those errors can include inadequate follow-up or monitoring of treatment.

Because preventive care is both population-based and periodic, it's difficult to track with paper records when patients receive preventive services like flu shots and mammograms. Even if your practice tries to keep tabs on a handful of preventive interventions, you're likely to miss some key measures.

A disease like diabetes—which has so many different indicators-is a good example of how chronic diseases can overwhelm physician practices. You need the ability to quickly spot a select population of patients, track them and apply recurring interventions using a specific protocol.

What EMR features can help you manage preventive care services? Look for the ability to do ad-hoc, population-based queries that let you identify patients based on age, gender, diagnosis and other related criteria.

You'll also find the ability to set recurring alerts by a user-defined population extremely helpful when it comes to preventive care. Your software should come with a user-configurable preventive care module, which will allow you to create a set of interventions you can apply to a specific population.

Tests and procedures

Every day, your practice processes dozens of tests. Problems arise, however, when the tests you order are not performed. Sometimes patients simply fail to show up, but what happens when you or someone in your practice misses abnormal results? Biopsy referrals, surgical consultations and other situations involving life-threatening illnesses can be particularly tough to stay on top of for an average practice.

EMR software can help prevent some of these problems by tracking referrals and test status—pending, completed or abnormal—and telling staff when to expect a result.

And electronic systems help make sure your patients don't go unexamined or untreated, while the capability to flag lab results as abnormal is a good reminder to physicians to follow up. Other systems simply establish an automatic "to-do" list, which is also helpful.

Choosing the right system

One of the tricks in choosing and using EMRs is that different products vary greatly in how well they address these areas. A few tips, however, can help you choose software that will maximize your error prevention efforts.

For one, make sure you're directly comparing features of various systems. This requires interaction with the system, preferably with a "limited capability" version or detailed scripted demos (the users create the scripts). Compare apples to apples, and don't be distracted by the extra bells and whistles that some systems offer.

Every system should update its knowledge base—such as lists of drugs and clinical guidelines—at least quarterly. Physician users should be able to adjust key functions such as alerts and warnings.

Make sure, for example, that you are able to decide which level of drug interaction prompts an alert. Most physicians quickly learn to ignore systems that trigger indiscriminate interaction alerts—and may miss one that's important.

Finally, the ability to do population-based queries—to aggregate patients by key traits, age, gender or diagnoses—is essential for managing preventive care and chronic illnesses efficiently and effectively. It can also be critical for launching quality initiatives in your practice.

Jerome H. Carter, FACP, is director of informatics at the 1917 Research Clinic in the division of infectious diseases at the University of Alabama at Birmingham. He is the former Chair of ACP's Medical Informatics Subcommittee and edited "Electronic Medical Records: A Guide for Clinicians and Administrators," published by the College in 2001.


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