Epic is a powerful tool, but beware its hidden hazards

Steven Freer

Steven D. Freer, M.D., FACP
Isidor Brill Chair, Department of Medicine
Medical Director, Hospital Quality and Patient Safety
Providence St. Vincent Medical Center

Feb. 19, 2014

Almost two years after the launch of Epic, most of us have settled into a workable truce with this powerful and complex tool. We have begun to see how it can improve the way we care for patients, through better access to information, better medication accuracy and other enhancements in patient safety

Yet this technological innovation also carries the potential for serious hazards. Providence St. Vincent Medical Center's quality management leadership team recently examined a sentinel event that revealed an alarming confluence of these hazards, resulting in protracted hospitalization and inappropriate care. Events such as this are a cautionary tale for all of us using Epic or any similar electronic health records system.

This case had a relatively positive outcome, but we were left with an ominous sense that the next time our fortunes might be quite different.

So what are some of these hazards? Many of them lie in the elusive promise of convenience and efficiency. Consider your daily interactions with Epic, whether in the notes you write yourself or those entered by others. Like a medication that can either save a life or ruin it, EHR can enhance or diminish the reliability and safety of patient care, depending on how it is used.

  • Dot phrases save us time, but carelessly deployed, they convey information that is imprecise, misleading or erroneous.
  • Propagating information from one day to the next may seem efficient, but if we fail to edit and update the information, important changes go undocumented.
  • Cut-and-paste capabilities are convenient, but notes can swell with extraneous and redundant information. Searching for the relevant content becomes onerous and time consuming, raising the prospect that important information will be missed.
  • Templates may simplify documentation, but they create a serious temptation to note things “more or less” considered. In the most egregious examples, pre-populated notes contain elements not corrected for accuracy. Anyone who relies on that note for clinical decisions does so with the dangerous assumption that the information within it is correct. Since much of this charting is driven by a need to meet billing criteria, it also exposes us to allegations of fraud.
  • Voice-recognition software has improved dramatically over the past decade, but we still see notes full of nonsensical words, clauses and syntax. Adding a disclaimer that warns of potential inaccuracies shifts the burden of verification to the reader, and has proven an extremely tenuous barrier against legal and ethical criticism.

By signing a note, we attest to the accuracy of everything in it. We are legally and ethically accountable for all its contents. A template that identifies normal exam findings presumes that the exam was done. A dot phrase that includes “I have personally reviewed all relevant studies…” means exactly that.

All of this may seem self-evident, and yet repeatedly, we see notes that fail on these very basic principles. Although these errors only surface when something goes wrong, charting inaccuracies are far more common than the rare catastrophe would suggest. Each is disaster-in-waiting.

It is noteworthy that the Oregon Medical Board, along with the Federation of State Medical Boards, has taken up this very issue around the hazards of electronic charting and is actively considering practice standards.

If used improperly, even the finest tools are dangerous. EHRs are a remarkable technological tool, with the potential to improve health care delivery and outcomes. It is our professional obligation to assure that in using them, we do not create unanticipated risks for our patients and our colleagues.