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April 2017

Huddle Up
By Lisa A. Eramo, MA
For The Record
Vol. 29 No. 4 P. 14

Can daily staff gatherings improve EHR functionality and mitigate patient safety risk?

Sports teams do it before and during games. Pilots and their aircrew do it before a flight. Nurses do it before their shifts begin. We're talking about huddles—coming together to identify potential challenges and formulate a plan for success.

It seems like a logical approach to ensure a positive outcome. So why don't all hospitals do something similar as a sort of daily game plan to ensure patient safety in an electronic environment? The focus of these huddles would be the EHR—the single most important piece of technology that drives almost every action and clinical decision within the organization.

Making Teamwork a Priority
At least one hospital is currently holding daily huddles. In fact, its efforts are the focus of a research study published in the Journal of the American Medical Informatics Association (JAMIA). The study, which focuses on the use of huddles for identifying and learning about EHR-related safety concerns, took place at Baylor Scott & White Medical Center in College Station, Texas, a facility that opened its doors in August 2013 and simultaneously went live with an EHR.

During 20- to 30-minute daily huddles led by hospital leadership, representatives from the clinical, IT, and administrative departments—typically 30 to 40 people—met to discuss various types of safety issues that occurred in the last 24 hours as well as potential problems that could occur in the next 24 hours. This included issues related specifically to the EHR (eg, device failure, loss or delay of data, errors in data display) as well as general safety concerns such as patient falls, needle stick injuries, diagnostic errors, and health care–associated infections.

"Huddles bring people together to try to solve a complex problem, and they also increase the situational awareness and mindfulness of an organization," says Hardeep Singh, MD, MPH, one of the study's researchers and chief of the health policy, quality, and informatics program at the Houston VA Health Services Research Center of Innovation and Baylor College of Medicine.

Dean F. Sittig, PhD, a coauthor of the study and a professor at the UTHealth School of Biomedical Informatics, agrees. "So many of these things aren't hard to fix—it's just a matter of getting the message to the right person," he says.

At the conclusion of each huddle, participants reported significant safety issues directly to executive leadership, as well as a safety officer, within the quality and risk management departments. They discussed less significant issues in smaller groups. Members of the quality department followed up with all unresolved issues to ensure nothing was overlooked.

Singh and other researchers analyzed the notes taken during the huddles so they could classify safety concerns into the following six categories:

• hardware and software (the computing infrastructure used to power, support, and operate clinical applications and devices);

• clinical content (the text, numeric data, and images that constitute the language of clinical applications);

• people (everyone who interacts in some way with technology, including developers, users, IT personnel, and informaticians);

• workflow and communication (processes to ensure patient care is carried out effectively);

• human-computer interface (all aspects of technology that users can see, touch, or hear as they interact with it); and

• internal organizational features (policies, procedures, work environment, and culture).

In total, their analysis included 245 EHR-related safety concerns over the course of 249 days. This represents 7% of the more than 3,000 different safety concerns that were identified during the same time period.

Nearly 33% of the EHR concerns fell under the hardware and software category, 22% were related to clinical content, and 20% fell under the people category.

Sittig says the results point to a shared responsibility between vendors and providers to ensure patient safety in an electronic environment. "The vendors need to build the systems correctly, but then the organization must configure and use the systems correctly," he says. "Somewhere between the two is where most of these mistakes are occurring."

People, Processes, and a Systematic Approach
EHRs have a significant potential to improve care—but only when implemented thoughtfully and with a systemwide focus on safety, says Elizabeth A. Regan, PhD, an associate professor of HIT and department chair of the integrated IT department at the University of South Carolina.

She references the Institute of Medicine's report "To Err is Human: Building a Safer Health System," which states, "Mistakes can best be prevented by designing the health system at all levels to make it safer—to make it harder for people to do something wrong and easier for them to do it right."

"This is the first major report that called for the transition to electronic health information as part of improving our US health care system," Regan says.

The Joint Commission also has focused on the importance of uniting people and systemwide processes during an EHR implementation. A 2008 Joint Commission Sentinel Event Alert states, "Any form of technology may adversely affect the quality and safety of care if it is designed and implemented improperly or is misinterpreted. Not only must the technology or device be designed to be safe, it must also be operated safely within a safe workflow process."

A 2015 Joint Commission Sentinel Event Alert also references the importance of proper workflow design, stating that "well-designed and appropriately used EHRs coupled with strong clinical processes can improve and monitor health care quality and safety through their ability to access important medical history data, provide clinical decision support tools, and facilitate communication among providers and between providers and patients."

However, Sandra Routhier, RHIA, CCS, CDIP, vice president of revenue integrity at CloudMed Solutions, says vulnerabilities inherent in the technology make it difficult to ensure safety.

Having previously worked as a consultant, she saw many hospitals struggle with safety issues stemming from functionality originally designed to expedite user efficiency. For example, in one hospital, physicians could create a discharge summary using an autopopulated template. However, the template was designed to pull information from admission labs, not discharge labs. Routhier says the scenario had gone completely unnoticed until she brought it to someone's attention.

"Of course, everything in the computer is due to a human at some level," Sittig says. "I think we are most worried about the errors that are propagated for an extended time, such as the display of the wrong labs on the discharge summary described above. Those types of systematic errors didn't occur in a paper system."

Copy-and-paste functionality is another vulnerability that can wreak havoc when used improperly. Imagine the confusion that occurs when a physician copies and pastes documentation stating "patient is sleeping and hemodialysis is in progress" on a daily basis when in fact the patient receives dialysis every other day.

"It scares me to think that if the record is being used to make clinical decisions, it could lead to poor outcomes," Routhier says.

Many EHR-related safety problems are born when organizations first implement the technology, a time when IT professionals must set literally thousands of configuration parameters prior to go-live, Sittig says. For example, proper access so a nurse can print to a device on his or her unit must be set up. If the nurse can't access that printer properly, it isn't a vendor issue, it's an implementation problem, Sittig says. "The print function worked just fine, but what happened was that the hospital didn't configure it properly," he notes.

The EHR is also vulnerable during upgrades to the system. "There are a whole bunch of changes at once. It's a complex system with a lot of interacting parts, and sometimes people don't understand how things interact," Sittig says.

Nevertheless, it's much easier for health care organizations to blame the EHR vendor when problems arise rather than examine their own internal processes and workflow, Regan says. "I'm very cautious about the safety issue. I don't ignore it, but I think it could be a red herring in many cases," she says, adding that many research studies indicate that EHRs greatly reduce or even eliminate errors when implemented correctly and with proper workflow and process changes.

"We have to be cautious," Regan says. "How do [EHR safety issues] compare with issues we saw before we implemented and made the transition to EHRs?" Without benchmarks, "perceptions are seldom what they seem," she adds.

Why EHR Safety Huddles Work
Given the prevalence of configuration issues and "people problems" with EHRs, it makes sense that safety huddles—the goal of which is to bring people together to facilitate communication—would be so successful.

Another reason is the blame-free culture in which huddles tend to take place, Sittig says. "If you have that type of culture, I think people are much more likely to say something," he notes.

Huddles also reinforce the idea that the EHR is a work in progress. "So many people don't seem to understand that when you put these systems in, there's a long maintenance or optimization phase that you need to go through," Sittig says. "That's what we were trying to show with this [study]. How do you collect data, keep track of it, and make sure that people are fixing the system?"

Regan agrees, "A lot of it has to do with whether the implementation is viewed as the end point or the beginning point of improving the delivery of care. Just putting the technology there doesn't do much for improving anything."

In the JAMIA study, the proportion of EHR-related safety concerns was higher in the go-live stage (12.6%), and remained constant at about 7% in the final three months.

Viewing the EHR implementation as an ongoing effort requires visible CEO commitment and an organizationwide focus on mission, vision, buy-in, and creating a compelling need for change, says Regan, whose own research has led her to the conclusion that organizations with successful EHR implementations that improve rather than inhibit the delivery of care also have the following nine themes in common:

• focus on patient-centered care and engagement;
• quality focus with clinical benchmarks for monitoring success;
• workflow integration;
• strong physician leadership;
• training and involvement, including clinician engagement;
• supportive organizational climate for innovation;
• collaborative culture;
• systems perspective on change; and
• technology reliability, responsiveness, and interoperability.

All hospitals can benefit from EHR safety huddles, particularly those that might have rushed meaningful use initiatives in order to qualify for state and federal financial incentives. "Everyone is always moving on to the next thing. They don't go back and revisit those things that could have been improved at the time of implementation. It's hard to get the time and resources to do that, but it's very necessary," Regan says.

Bringing Everyone to the Table
Experts agree that EHR safety huddles should include a cross-section of departments, including IT, lab, radiology, admitting, nursing, physicians, and HIM.

Unfortunately, HIM professionals are sometimes overlooked when it comes to HIT initiatives, Routhier says. "HIM isn't always at the table when some of these decisions are made," she says. "But we have education and expertise that can be used to help protect the quality of the documents that are being created and stored in the health record."

What about vendors? Should organizations include EHR vendors in these huddles?

Typically, the answer is "no," Sittig says. "The vendor is a pretty small player in most of these issues. If you think about it, these systems have been used by thousands and thousands of people," he says. "The chance that you're going to find a bug that no one else has seen before is pretty small."

However, organizations do need an open communication channel with their vendor as well as clear mechanisms to escalate high-priority questions and concerns, Routhier says.

Finding the Right Combination of Solutions
Although effective, safety huddles are only one method that health care organizations can use to better understand patient safety risks in the EHR.

Another method that works well is implementation of a robust incident reporting system that includes a separate category for EHR safety issues, Routhier says. This allows organizations to track and trend their data to identify whether the problem relates to a particular provider, document type, data field, or template, for example.

However, organizations need to review their reporting procedures to ensure they are effective and not too cumbersome. Physicians often do not report incidents, especially if it interrupts workflow, takes too much time, or a follow-up answer addressing the incident is not forthcoming, Singh says. Organizations must build a culture of learning, action, and feedback based on these reports, he adds.

Routhier suggests performing clinical quality reviews similar to the clinical pertinence reviews once required by The Joint Commission. During these reviews, auditors validate not only whether detailed information is present in the record but also whether that information is actually relevant to the admission and whether it demonstrates safe and high-quality patient care. Routhier cites the example of an organization ensuring that all nurses record stop times for medication administration.

HIM professionals, clinical documentation improvement specialists, and IT trainers are well suited for the role of clinical quality reviewer, Routhier says. Depending on the size and resources available at the facility, it could be either a formal dedicated role or a duty added to an existing job description. Clinical quality reviews could also be the responsibility of a multidisciplinary team—even transcriptionists and coders can help with the effort. The goal is to empower anyone reading the record to speak up when noticing conflicts and potential safety issues, Routhier says.

For example, consider a physician who switches back and forth between left and right knee when describing a knee replacement surgery or a physician who documents severe protein calorie malnutrition for a patient whose templated emergency department record and history and physical states, "well-developed and well-nourished female."

"Is that dangerous? Maybe, maybe not, but it's still a conflict that needs to be resolved," Routhier says.

Regardless of whether it's from huddles or reports, learning from aggregated data is also helpful. Health care organizations may not have the bandwidth available to analyze safety huddle data using the methods described in the JAMIA study, but Singh says even basic tracking and trending is worthwhile. For example, noting date and time patterns of a specific event, such as EHR downtime occurring at a specific time, may be valuable. "You can still make a lot of progress with the safety data you have as long as you are committed to learning from it," Singh says.

Once data have been collected, facilities can consider using the Office of the National Coordinator for Health Information Technology's SAFER Guides for EHRs to develop an action plan. These nine guides—developed by Sittig, Singh, and their research team—help identify recommended practices to optimize the safety and safe use of EHRs.

Finally, Regan says to consider the extent to which errors may be the result of more systemic problems that could trigger innovative improvements in the process of care. For example, if physicians frequently override standard protocols in the EHR, might this be an opportunity to discuss potential improvements in those protocols?

CEO buy-in is essential in addressing these systemwide hurdles, Regan says. "Only the CEO has the power to authorize, incentivize, and/or remove barriers for major cross-functional change initiatives," she notes.

— Lisa A. Eramo, MA, is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.


Safe implementation of new technologies and therapies accompany classic patient safety challenges on ECRI Institute's 2017 Top 10 Patient Safety Concerns for Healthcare Organizations. The report highlights concerns from HIM, clinical decision support, and new oral anticoagulants to long-standing concerns like test result reporting and follow-up and unrecognized patient deterioration.

ECRI Institute relied on its Patient Safety Organization (PSO) event data, concerns raised by health care provider organizations, and expert judgment to select the topics for the 2017 list. Since 2009, when ECRI Institute PSO began collecting patient safety events, the PSO and partner PSOs have received more than 1.5 million event reports and reviewed hundreds of root cause analyses.

"The 10 patient safety concerns listed in our report are very real," says Catherine Pusey, MBA, RN, associate director at ECRI Institute PSO. "They are causing harm—often serious harm—to real people."

This year's list includes the following:
• information management in EHRs;
• unrecognized patient deterioration;
• implementation and use of CDS;
• test result reporting and follow-up;
• antimicrobial stewardship;
• patient identification;
• opioid administration and monitoring in acute care;
• behavioral health issues in nonbehavioral health settings;
• management of new oral anticoagulants; and
• inadequate organization systems or processes to improve safety and quality.

Topping the list this year is information management in EHRs. Health care providers have troves of information to manage, and the advent of EHRs has brought this challenge to the forefront.

"But the object is still for people to have the information that they need to make the best clinical decision," says Lorraine B. Possanza, DPM, JD, MBE, program director of Partnership for Health IT Patient Safety at ECRI Institute. "Health information needs to be clear, accurate, up to date, readily available, and easily accessible."

— Source: ECRI Institute