Multiple open charts
Background
Medical errors can be classified in the realm in which they occur (medication, surgical error or healthcare technology) with some overlap across each. Passage of the HITECH Act led to increased funding for the advancement of healthcare technology with incentive payments for EHR adoption and its meaningful use, which included CPOE (computerized provider order entry).
With increasing EHR adoption came increased concerns regarding technology induced medical errors as well as efforts to increase patient safety through the creation and enforcement of several quality measures.
The Joint Commission and Office of the National Coordinator for Health Information Technology currently recommend restricting providers to having 1 open patient record at a time in the EHR in an effort to reduce CPOE errors as a result of wrong patient selection.[1] Of the studies evaluating the effect of number of open records on patient safety, two studies cited by the ONC suggested a possible correlation between multiple open records and patient selection errors.[2,3] However, neither of these studies evaluated the impact of multiple open records on patient safety. With a lack of strong evidence either positively or negatively correlating RAR events with the number of open records, implementation of ONC SAFER guidelines as it pertains to multiple open records as varied. This conflicting data has led hospital decision makers to choose the number of allowable open records based on personal preference, anecdotal evidence or a combination of the two.[4]
Quantifying CPOE Errors
One of the first representations of a health system utilizing information technology to track computerized provider order entry errors was described by Classen and colleagues in 1992.[5] In this study, the creation of a computerized adverse drug event monitor integrated within a hospital informational system database allowed tracking of CPOE errors.
Following this study, an analysis by Koppel et al.[6] was one of the first to suggest implementation of information systems to help identify rapid order discontinuation as a surrogate marker for a prescribing error, also known as retract and reorder (RAR). RAR is more specifically defined as an event in which an order written for a patient is cancelled and reordered for a different patient within 10 minutes. Following these earlier studies, tracking RAR events has since been suggested as a method to identify orders with a high probability of reflecting medical errors. Since then, there have been several publications quantifying CPOE errors using RAR events.
Provider resistance to limiting number of open records is primarily due to:
- Decreased perceived efficiency
- Workflow interruption through removing ability to multitask
Potential effects of limiting number of open records
- Creation of unsafe workarounds to improve clinician efficiency
- Potential to increase CPOE errors as a result of forced task switching
Current Literature
A national survey[7] evaluating the number of records allowed open in EHRs at hospitals and ambulatory sites showed significant variation in allowable number of open records with many site respondents with 1 allowable open record reporting increased patient safety as a benefit, while those allowing more than 3 open records at a time citing greater efficiency and ability to multitask. However, it is worth noting that within the same survey, several respondents reported that providers working in environment that were constrained to one open record such as the use of multiple browsers or workstations which inherently has its own safety concerns. They also noted lack of evidence regarding the degree of impact of the number of open records on patient safety.
A recent randomized controlled trial including 3356 clinicians at a large health system divided clinicians into groups, limiting them to 1 patient record open at a time or allowing up to 4 records concurrently.[8] Primary outcome was order sessions that included 1 or more wrong patient retract and reorder measure. The study found that an EHR configuration limiting clinicians to 1 open record vs 4 open records concurrently did not significantly decrease the proportion of CPOE errors attributable to patient selection error. However, they did note that clinicians in the unrestricted group placed most orders with a single record open (66.2% of order sessions in unrestricted group were completed with 1 record open), potentially limiting the power of the study.
A sub study of the same trial evaluated the effect of limiting number of open records on clinician efficiency, defined as total active minutes a day.[9] Surprisingly, results of the study found no significant difference between provider groups limited to 1 open record vs up to 4 records concurrently. The findings of these recent studies will hopefully provide further evidence to help inform national recommending bodies such as the ONC SAFER Guidelines as well as hospital decision makers when deciding on optimal EHR configuration.
References
1. The Office of the National Coordinator for Health Information Technology. Safety Assurance Factors for EHR Resilience. https://www.healthit.gov/topic/safety/safer-guides.
2. Galanter, W., Falck, S., Burns, M., Laragh, M. & Lambert, B. L. Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). J Am Med Inform Assoc 20, 477–481 (2013).
3. Levin, H. I., Levin, J. E. & Docimo, S. G. ‘I meant that med for Baylee not Bailey!’: a mixed method study to identify incidence and risk factors for CPOE patient misidentification. AMIA Annu Symp Proc 2012, 1294–1301 (2012).
4. Kannampallil, T. G. et al. Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department. J Am Med Inform Assoc 25, 739–743 (2018).
5. Classen, D. C., Pestotnik, S. L., Evans, R. S. & Burke, J. P. Description of a computerized adverse drug event monitor using a hospital information system. Hosp Pharm 27, 774,776-779,783 (1992).
6. Koppel, R. et al. Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. J Am Med Inform Assoc 15, 461–465 (2008).
7. Adelman, J. S. et al. A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites. J Am Med Inform Assoc 24, 992–995 (2017).
8. Adelman, J. S. et al. Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial. JAMA - Journal of the American Medical Association 321, 1780–1787 (2019).
9. Kneifati-Hayek, J. Z. et al. Effect of restricting electronic health records on clinician efficiency: substudy of a randomized clinical trial. J Am Med Inform Assoc 30, 953–957 (2023).
Submitted by (Taina Hudson)
