Be Very Careful When Using EHR Shortcut Features

Some years ago, I heard a physician discussing the limited time that providers in the real world have to document patient encounters. He is an emergency department physician, and he talked about the use - and misuse - of WNL: Within Normal Limits. Originally intended to provide physicians with quick shorthand when dealing with patient symptoms and test results, it allowed some ability to provide rapid documentation of patient parameters that were considered nominal. Unfortunately in the heat of the battle, so to speak, the timesaving characteristics can be misused - or even abused - leading to negative consequences. That leads many - including the ED speaker - to cynically observe that WNL doesn’t always stand for Within Normal Limits; sometimes it stands for We Never Looked.

Unfortunately in some cases the negative consequences can be disastrous. And with the automation involved with EHRs and other health IT systems, the errors can occur quicker, cover a larger number of patients, and potentially be more subtle and harder to track down and rectify later.

With most current-generation EHRs, there are many shortcuts and time savers built in to enable clinicians and other users to handle patient matters more efficiently. Pre-populated templates, drop-down lists, copy/paste functionality, etc., all provide unprecedented ease of use and convenience.

Copying data from one patient’s electronic record to another, or using a predefined term or phrase to refer to a cache of verbiage, may be completely appropriate, but only if the content and context is truly appropriate.

The problem isn’t in the EHRs themselves, it is in how they are used. We are reminded of a common phrase: "To err is human; to really screw things up requires a computer.” The challenge with such features as cut/copy/paste, auto complete, auto fill, etc., is that they can be easily used inappropriately, and it is usually not possible to determine - after the fact - if such shortcuts were used, and if so, if they were used inappropriately.

And the less training and work flow redesign involved in the implementation of an EHR or other system, the more likely it is that they will be used inappropriately.

Many observers point to these issues as a reason to eschew EHRs completely, claiming that EHRs and related IT-enabled medical tools are dangerous or reckless, fraught with issues closely akin to HAL in “2001, A Space Odyssey.”

But, in fact, the misuse of this feature of EHRs is just like the misuse of any tool or device in medicine. If you put a knee scope, a cauterizing device, or a Da Vinci surgical robot in the hands of a careless or inattentive or untrained user, it can have disastrous consequences.  

There are no statistics - only anecdotes - of the effect of errors brought about by EHRs and related healthcare IT systems. But there are many statistics on the effect of medical errors due to manual/paper processes. A statistic that seems to have caught on several years ago and persisted through many articles in the media is that nearly 7,000 people die each year by illegible handwritten prescriptions alone. Drug side effects and drug/drug interactions are generally accepted as being one of the top five leading causes of death.  Presumably both would be easily solved by the proper, widespread implementation, and use of EHRs.

So the idea that EHRs should be avoided because of real or perceived negative effects on patient safety is incorrect thinking. What should be emphasized is better selection, implementation, and training, including everything from user security (to not only satisfy HIPAA Security but to prevent users from inadvertently accessing the wrong record), to device design and placement (making sure the clinician can clearly see what data fields are being accessed and modified), to error checking and reporting.  Also included should be thorough training of all users, as well as work flow redesign. Unfortunately, in too many cases, the training for the clinical and business office staff is trimmed down (since the user interfaces look “easy”) and the archaic work flow is kept intact (“We don’t have time to make a lot of changes…let’s just get the system up and running and we’ll optimize it later.”).

EHRs - when properly selected, implemented, and optimized - can have a definite positive effect on patient safety as well as increased efficiency of the business office and clinical staff. On the other hand, the exact same system can be a potential nightmare for both functionality and patient outcomes.

It completely depends on the user(s).