Monitoring and Evaluating the Use of Electronic Health Records

To the Editor: In their Commentary on the need for a comprehensive monitoring and evaluation framework for electronic health record (EHR) use, Drs Sittig and Classen¹ called for a national EHR adverse event investigation board, similar to the National Transportation Safety Board. I believe that this approach confuses systemic errors within EHRs with errors caused by inadequate EHRs and would miss almost all of the latter.

Sittig and Classen called for reporting structures for catastrophic system-caused errors, for example, in which all patients prescribed one drug receive another. However, it is likely that there are far more errors and near misses associated with poor but not obviously catastrophic design (for example, EHR screen displays that obscure critical information, drop-down menus reflecting inappropriate options, or oversensitive drug-drug interaction alerts). These types of near misses and errors may be unrecognized, underreported, and attributed to inadequate physician training or commitment.

There are a number of reasons such medical errors may be undetected. Clinician health record analysis may miss errors linked to undocumented, improper, or delayed diagnosis entries.² Clinical presentations are complex and may involve obscured causes, polypharmacy, or multiple systems problems.³ Self-reports of prescribing errors are rare because they are seldom recognized and may also be limited by concerns of litigation and status loss. Errors intercepted by colleagues and pharmacists may often be corrected informally and infrequently reported. Observational methods are expensive and are likely to catch procedure mistakes and errors of medication administration or dispensing rather than misdiagnoses, missing information, or poor prescribing. Sentinel or trigger signals quickly generate alert fatigue and are not standardized; computerized decision support alerts may be overridden 80% to 96% of the time.⁴

Although Sittig and Classen correctly emphasized monitoring systemic failures of EHRs, EHR-linked errors and near misses must also be addressed. A program to identify, monitor, and remediate such EHR-engendered errors should accompany the efforts to promote EHR use.