April 7, 2021 - by Parul Saini, Webmedy team
With the rapid adoption of electronic health records (EHR)s and health technology (health IT) tools, the ONC (Office of the National Coordinator for Health Information Technology) has been very concerned about the safe use of these tools. A simple human error such as selecting the wrong option from given choices results in big trouble.
An electronic health record (EHR) is a real-time, point-of-care, patient-centric information resource for clinicians, that represents a major domain of health information technology (HIT). EHR involves patient information such as a problem list, procedures, medications, vital signs, past medical history, notes, laboratory results, and radiology reports, among other things. The EHR creates a complete record of a clinical patient encounter or episode of care and underpins care-related activities such as decision-making, quality management, and clinical reporting. Some differentiate between the terms EHR and electronic medical record (EMR), with EMR focusing on ambulatory care systems. But, in practice, the terms are interchangeable.
Orders for patients are the connective tissue in any EHR. They are patient-specific interventions across the departments, which are written by members of the health care team, doctors, and staff. Orders management crosses customary boundaries, and it is just as likely to integrate computerized applications and functions as it is to separate traditions. For instance, information once the purview of one department becomes shared across many disciplines. Who owns data, such as a patient's allergies or weight, becomes a topic of vigorous discussion. New work processes are crafted. Because of the complexity of order management, computerized physician order entry (CPOE) has been a topic of research.
EHRs are changing the way patients receive care, in particular by providing healthcare workers new tools to give better quality and quality care. The Healthcare industry is in somewhat of a strange position when it comes to EHR use and patient safety. When properly applied, there have been many advancements in EHR capabilities that have made care much safer. Examples involve standardized electronic order sets, care pathways with combined clinical decision support and workflows, drug selection and dosing decision support, automated surveillance and alerting, and automated workflows to enhance process reliability.
But most hospitals lag far behind in the adoption of some of these capabilities and, more importantly, in optimization of EHRs and clinical processes to meet local conditions and patient needs, So there is a lot of potential but not early enough progress. The problem is that now that we have EHRs, it's easier to see the errors, and we all thought that by putting in a computer system we would stop making errors. That was the goal, but we didn't get there. People are still making mistakes but now we can fix them.
Picklists, also known as drop-down lists in an EHR, are often used when a provider first enters patient information, and subsequently orders prescriptions and dosages for each patient. While pick list errors can occur during several tasks in the medication management process, here are two error types:
Standardize the names for drugs to make sure that users know which medication they are prescribing no matter which clinical terminology they are most comfortable using. Providers, EHR vendors, and other stakeholders should standardize their terminology and develop best practices for displaying information,
Standardize the organization, design, and configuration of all EHR pick lists so that users can easily read and identify options and choose the correct entry in an intuitive manner. Font sizes, spacing, capitalization, and color-coding should all be standardized across drop-down menus to ensure that cognitive dissonance does not result in erroneous selections.
Developing a summary review screen that could be viewed before a medication order is finalized. This will help the user to double-check that they have picked the right medication with the appropriate dosage.
This strategy can help assure that providers are working with the correct record by triggering provider recall, and may also decrease a variety of other wrong-patient documentation issues.
By giving all the patients a summary of every visit as per their current medication along with information on why each medication is prescribed to them.
By adding these capabilities make it easier to collect data and to revise the incorrect orders. It will help in tracking the root cause of the error during the medication ordering process, including pick list-related errors.
The above-mentioned ideas focus on ambulatory care settings, such as doctors' offices or hospitals. In a busy clinical setting, our top priority is communicating with patients and clearing their doubts. And same information must be entered into clinical notes and patient medication lists. To improve both the reliability of medication information patients depend on and the accuracy of data used for research.