EPR linked to patient safety: a proposal.

Article originally posted July 28th, 2016, in HIMSS Europe's blog, and revised August 28th, 2016. Reposted with permission of HIMSS Europe.

“All men make mistakes, but a good man yields when he knows course is wrong, and repairs the evil. The only crime is pride.”— Sophocles, Antigone

Avoiding patient harm is the next challenge for the healthcare industry. Everywhere. When we stop and think about it, the words which spring to mind include “surgical checklists”, “safety procedures”, “hand washing” and so on.

But what about EPR? What can we do about patient safety from an EPR / EHR / EMR point of view?

The problem

Let's consider the following scenario: patient harm due to medical errors.

Most of these errors are avoidable. In 2013, the “Journal of Patient Safety” stated that there are between 210.000 to more than 400.000 premature deaths per year in the U.S. which are associated with preventable harm to patients.

In Spain we’ve got statistics from “Asociación de Defensa del Paciente”, which calculate the number of litigations due to medical errors. In 2015, there were 14.430 medical errors cased (the majority of them related to waiting list issues), of which 806 resulted death.

It’s a shame.

Its worth noting that these numbers are of course influenced by the number of lawyers who are encouraging patients to sue when any complaint relating to sub standard care is made. That means increasing costs of medical practice costs for all healthcare professionals due to the growing costs of civil responsibility insurances. This can clearly be seen in the US but also we are beginning to see it in Spain, too.

How to fix it

What can be done to solve this problem?

Surely there are a lot of things we could do.

We could, for example, improve the decision-making processes. In particular, we could examine how a doctor evaluates vital signs, symptoms, laboratory test results and diagnostic images to determine a given diagnostic.

These kind of processes are supported by clinical guidelines, approved by the CMO, or provided by healthcare regional and national administrations. These guidelines include a decision-driven flowchart (or something similar) which specifies each step the doctor should follow. It’s the safest way to conduct diagnostic treatment processes, because they are evidence based, peer-reviewed procedures. Following a clinical guideline is safe for the patient, but also for the healthcare professional. And it’s cheaper for all the stakeholders, too.

And what about EPR? Well, the implementation of clinical guidelines in a commercial EPR tends to be a limited document attachment with no business rules embedded into it, except perhaps for the possibility to provide an alert when a given condition has been identified (for example, a threshold value for a vital sign or a specific diagnostic).

The proposed solution

What needs to be done? The decision flowchart needs to be imbedded as a set of business rules into the EPR. What this means is that the EPR would follow a diagnostic decision-making process driven by clinical guidelines, assessing the healthcare professional in each step, proposing suitable diagnosis and treatment options at every step, avoiding mistakes and protecting patients with the safest, most convenient procedures.

This means that the EPR would be transformed from an input tool with limited intelligence to a veritable medical record and assessment tool. A system designed to improve patient safety. The EPR in this context should be a system that is preventing harm. That is our goal.

Consider, for example, a female patient, with suspected breast cancer. All the symptoms and tests reveal that it’s breast cancer. But the healthcare professional didn’t have access to the biopsy results. And without them, they can’t make a final diagnosis of breast cancer. A typical commercial EPR, would allow this perosn to record a final diagnosis of breast cancer. 

In our proposed smart EPR it would alert us to the fact that biopsy results are missing, and offer the option to order them if we hadn’t already done so, showing a CPOE window with the relevant options pre-selected.

This is only one example of how we could improve patient safety using an EPR.


There is a lot of work to do.

One of the most famous quotes from Star Trek is: "To boldly go where no man has gone before..."

It’s time to come together, explore the EPR technology boundaries, with a view to ultimately improving patient safety.

This is one of topics to be discussed at the new HIMSS Europe World of Health IT (WoHIT) Conference & Exhibition which will be taking place on 21–22 November 2016 in Barcelona, Spain (www.worldofhealthit.org).