As part of the American Recovery and Reinvestment Act of 2009, the government is investing billions of dollars to encourage health care providers to use electronic health record systems. Many providers will probably switch from older systems to new systems to qualify for the federal incentives, but whether the upgrade improves patient care and safety has remained an open question.
To address this issue, a team of physician-scientists from Weill Cornell Medical College tracked the prescription errors of 19 physicians in an adult ambulatory clinic before the switch from an older to a newer system, then again 12 weeks after the switch and once again a year later. The new electronic system provided extra guidance for prescribing to improve safety, such as alerts notifying providers about use of inappropriate abbreviations that can result in patient harm, as well as checks for drug-allergy interactions, drug-drug interactions and duplicate drugs.
In total, the researchers analyzed nearly 4,000 prescriptions for more than 2,000 patients and noted mistakes in abbreviations, usage directions, dosage, the quantity of medications to be dispensed and more. They also gave a survey to assess physicians' views of the switch. The results were published recently in the Journal of General Internal Medicine.
The researchers found that the rate of prescription errors dropped by two-thirds, from about 36 percent to about 12 percent one year later. They also found that the rate of improper abbreviations, such as the outmoded "QD" instead of "once daily," fell by three-quarters, from about 24 percent to about 6 percent one year later; nonetheless, these remained the most common type of mistake at all three time periods. Meanwhile, the rate of non-abbreviation errors rose from about 9 percent to about 18 percent 12 weeks later, but it declined to the baseline level after one year.
"On the good side we found that the new system was very effective at reducing certain types of prescribing errors, such as inappropriate abbreviation errors. Averting these types of errors will likely result in fewer callbacks from pharmacies and improved efficiencies," says senior author Dr. Rainu Kaushal, chief of the Division of Quality and Medical Informatics in the Departments of Pediatrics and Public Health at Weill Cornell Medical College. But she cautions that "transitioning between systems, even among providers that are used to electronic health records, can be problematic."
For example, despite significant efforts to facilitate the transition, 40 percent of the doctors weren't satisfied with the implementation of the new system, and only one-third thought it was safer than the old one. In particular, 60 percent reported that the alerts weren't useful, and two-thirds indicated that the new system slowed down drug orders and refills.
To smooth the transition and further reduce prescription errors, the researchers suggest that the systems should be designed to detect and fix the most typical mistakes, as well as focus on the most clinically important mistakes so that providers don't begin to ignore alerts whenever they appear. Investigators should periodically reassess the effectiveness of such refinements, they add.
Moreover, doctors should receive individualized instruction and close follow-up attention. "Providers have substantial requirements for training and support," says lead author Dr. Erika Abramson, assistant professor of pediatrics and of public health at Weill Cornell Medical College and a pediatrician at NewYork-Presbyterian Hospital/Weill Cornell Medical College. "We need to make sure that the systems are easy for providers to use and don't cause workflow problems," she says.
The researchers probed physicians' perceptions in a companion study, and they plan to carry out a longer-term study that evaluates prescription errors two years after the upgrade.
"This important research provides the kind of recommendations necessary to ensure that physicians across the country can smoothly transition to electronic systems and use them in a way that makes medical care more effective and safer," says Dr. Alvin I. Mushlin, chairman of the Department of Public Health at Weill Cornell Medical College and public health physician-in-chief at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
"While the transition to electronic health records is not without its challenges, this study shows that making the transition, and broad support for this transition, is crucially important as it can significantly reduce errors," says Dr. Gerald Loughlin, the Nancy C. Paduano Professor and chairman of the Department of Pediatrics and senior associate dean for international clinical program planning at Weill Cornell Medical College, and pediatrician-in-chief at NewYork-Presbyterian Phyllis and David Komansky Center for Children's Health/Weill Cornell Medical Center.
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