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April 2, 2015

Joint Commission issues sentinel alert over EHR risks

Daily Briefing

    The Joint Commission on Tuesday issued a sentinel event alert, warning that while electronic health records (EHRs) and other health IT have the potential to improve care quality and safety, such technologies can pose inherent risks to patients.

    Details of alert

    According to the alert, which builds upon a 2008 notice that focused on safely implementing health IT and converging technologies, concerns about health IT include:

    • Complex human-computer interfaces;
    • Design issues that result in miscommunication; and
    • Poor health IT support.

    It stated that EHRs "introduce new kinds of risks into an already complex health care environment where both technical and social factors must be considered."

    The alert cited an analysis of event reports received by the Joint Commission showing that between Jan. 1, 2010, and June 30, 2013, hospitals reported 120 health IT-related adverse events. Of those errors:

    • About 33% stemmed from human-computer interface usability problems;
    • 24% stemmed from health IT support communication issues; and
    • 23% stemmed from clinical content-related design or data issues.

    The alert added, "As health IT adoption spreads and becomes a critical component of organizational infrastructure, the potential for health IT-related harm will likely increase unless risk-reducing measures are put into place."

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    The Joint Commission said that EHR systems must be well-designed and appropriately used in order to improve outcomes through their ability to:

    • Access data;
    • Provide clinical decision support tools; and
    • Facilitate communication.

    Specifically, the alert recommended:

    • Implementing comprehensive systematic analysis of all adverse events to determine whether they were the result of health IT issues; and
    • Limiting the number of patient records that can be displayed on the same screen at once (Rice, Modern Healthcare, 3/31 [subscription required]; Allen et al., "Morning eHealth," Politico, 4/1).

    The takeaway: An influential health care group is urging providers to review the design of their electronic health record systems and determine whether they have accessible data, provide clinical decision support tools, and facilitate communication.

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