A multidisciplinary panel that included physicians, nurses, pharmacists, EHR vendors, patients and health information technology experts, helped create 14 safety-based, rigorous test-case scenarios for vendors and health care organizations to use to evaluate the usability and safety of how the system is performing on a certain task. Running a scenario takes anywhere from 10 to 20 minutes.
The test-case scenarios are included in a report from the AMA, Pew Charitable Trusts and Medstar Health, Ways to Improve Electronic Health Record Safety. The report identifies shortfalls with EHR usability, implementation and testing, and outlines how to improve usability and safety across the continuum—from development to the post-implementation of EHRs.
The three organizations reviewed the medical literature and convened an expert panel of physicians, nurses, pharmacists, EHR vendors, patients and health IT experts. As a result of the panel’s work, leaders from the three organizations are calling on developers and health care organizations to voluntarily adopt the criteria and asking oversight organizations such as the Joint Commission to drive providers and vendors to incorporate the recommendations and adhere to the best practices throughout an EHR’s life cycle.
The criteria include several factors such as safety culture, product design and development, acquisition, customization and configuration, implementation and system upgrades, and training and provides EHR developers and health care providers with specific areas of opportunities for improvement within each EHR life cycle stage.
The 14 test cases included in the report can help tackle the usability and patient safety issues relating to data entry, alerting, interoperability, and more.
Physicians and their organizations can “immediately leverage” example test cases to “quickly evaluate system safety to identify challenges and prevent harm,” the report says. The report also outlines what constitutes a rigorous test case, so physicians also can create their own tests. The report says a rigorous test case needs to be representative, contain concrete goals and measures, test areas of risk or inefficiency, and define the audience.
Test case: Incomplete lab results
Here’s a closer look at a basic scenario to test whether your EHR will catch that a critical piece of information is missing from a patient’s laboratory work. The test takes about 10 minutes.
Particular area of risk or inefficiency. Multiple EHR systems have been noted to allow laboratory staff to release incomplete sets of labs without a placeholder for the unreported components of the blood test. For example, a basic metabolic profile typically contains seven elements. If only six results come back normal and the physician misses the seventh result, the patient could be discharged with a life-threatening condition.
Scenario. A 63-year-old male patient presents with vomiting and diarrhea for the past five days and is unable to tolerate food or water. The patient has a history of hypertension and glaucoma. He takes a “blood pressure pill and some eyedrops.”
1. Review the patient’s recent lab work. This should include a basic chemistry panel. There will be multiple abnormal results that are mild-moderate, including decreased kidney function, but no potassium reported because the lab is confirming the result and wanted to be helpful by releasing the other test results. This should not be pointed out to the user.
2. Order 1,000 ml normal saline bolus IV X 1STAT.
3. The nurse notices that the potassium is missing on the chemistry panel. You call the lab, which states that the potassium is being repeated because it was elevated. Place an order for an EKG to evaluate for hyperkalemia while the potassium results are pending.
4. The EKG shows normal sinus rhythm and shows no signs of hyperkalemia. Review the results again. (Potassium will be elevated at 5.8) You believe the results are consistent with renal dysfunction from persistent vomiting and diarrhea. Order a second 1,000 ml of normal saline and a repeat basic metabolic profile after the IV fluids to reassess the patient’s response.
The scenario fails if:
- There is no indication anywhere on the screen that there is a pending lab result.
- The participant does not make it clear in the electronic order that the second bloodwork should be sent after the second round of IV fluids is complete.
The moderator should note what the participant is able to see in the lab results section. For example, is there a placeholder for potassium in the chemistry panel of seven to eight results? Is it a missing row with no visual cue that one of the elements is still being tested and the panel is incomplete? Is there a reminder in a remote part of the screen that there are still pending results?
Among the other 13 scenarios the report lays out are tests for whether the EHR will:
- Alert a physician of a patient’s egg allergy when the patient comes in for an influenza vaccine.
- Properly handle a complicated medication scheduling task.
- Have proper interoperability when a physician must cancel an electronic prescription after realizing a patient had a bad reaction to the medication prescribed.