ERs are often busy places where events can occur at a pace faster than Mad Max trying to outrun a band of ruthless marauders, metaphorically speaking.

Shefali Luthra, writing for Kaiser Health News, described the scene best: 

"Sneaker-clad doctors and nurses rush between patients, often juggling multiple cases. ... Patients, even after being wheeled in by paramedics, can wait in a triage room for extended periods until a free nurse or physician comes to find out what’s wrong. It’s a different style of medicine, and one that’s often resulted in a distinct workflow."

With federal government incentives to use EHR systems in the ED, the "need for speed" could set up a "technology mismatch that creates challenges that aren’t necessarily as evident in other parts of the hospital," Luthra said. 

While new EHR models are more efficient and offer many benefits, they may require adjustments, to ensure accuracy, particularly in the ED setting.  

"The way the systems are set up, it can actually predispose to higher error rates," said Jesse Pines, MD, Office of Clinical Practice Innovation director at George Washington University in Washington D.C.

In a 2013 report, Pines, along with a panel consisting of 15 ACEP members, found that mistakes such as ordering the wrong medications, missing critical patient information, or even inputting information into the wrong patient record, were frequent occurrences, according to HealthLeaders Media (HLM). 

"Based on anecdote, it's incredibly common," Pines said. "If you ask any ED provider if they've had any of these events happen in the last six months, my guess is that universally, it will be rare to find someone who hasn't seen an issue, a near miss or actual error that's occurred."

The report outlined four types of "pitfalls" commonly seen in EHR systems: Communication failure, poor data display, wrong order or wrong patient error, and alert fatigue (frequent alerts can "dull the senses," the report said).

"As complex as it is, an EHR is simply a tool," further explained Randy Pilgrim, MD, FACEP, SCP Enterprise Chief Medical Officer. "As with every tool, it needs to be cared for, sharpened, honed, and used for its intended purpose. Failing to attend to the tool can lead to even more errors."  

Regardless of whether mistakes occur due to physician error or error on the part of the EHR system, the question is what can be done to prevent them? 

The report listed seven recommendations, some of which were directed at emergency department information system vendors, HLM said. They are:

  1. Each ED should have a clinician champion to lead a performance improvement group;
  2. Such a group should be multidisciplinary and meet regularly, to communicate with ED and hospital leadership;
  3. There should be a review process to monitor patient safety issues involving ED information systems; providers and others should be encouraged to submit safety concerns for consideration;
  4. Providers, vendors, and hospital administrators should address those concerns promptly, with "full transparency, specifically with openness, communication, and accountability";
  5. Lessons learned should be measured and shared publicly, including with other EDs using the same information systems;
  6. Vendors should learn from patient safety improvements and ensure timely distribution of necessary changes to all installation sites;
  7. EHR software vendor contracts should not include "Hold harmless" or "learned intermediary" clauses.

Aside from those included in the report, another recommendation is to have software designers spend time in the ER, observing the workflow under the most stressful conditions, with a goal of making EHR systems easier to use. Yet another is to get doctors' feedback on what works best or that could use improvement. 

Despite some drawbacks, particularly those related to current design, the situation will improve over time, Pines said. 

"I hope that market pressures will result in a much better product soon," added Stephen Nichols, MD, SCP Chief of Clinical Operations Performance. "I look forward to a system that makes the current ones look like an old cellphone, compared to a smartphone."

"Think about where we were even 30 years ago with cars," Pines also stated. "Cars are rapidly innovating to become safer and more efficient — and I think we can expect to see the same transformation in the electronic health record space."