EMR with Clinical Risk Management = Patient Safety: A Model for Success

Anne Huben-Kearney, vice president, risk management, ProMutual Group, Boston, MA, today presented “EMR with Clinical Risk Management = Patient Safety: A Model for Success.” We spoke with her to learn about her experiences working with a health information exchange and professional liability carrier and how and why risk management components can and should be implemented into an EMR.

What specific risk management components are needed in EMRs for addressing patient safety? How can they be implemented by the average practicing physician? We really looked at systems, tracking and follow up, and communication—the handoff between practitioners and the closing of the loop if you hand off to a specialist, making sure you get the reports back—and infection control, and that relates to all that you’re reading about with injections. We have both in the EMR, as well as some of the systems. Medication safety is one of the biggest things that we’ve focused in on, and that’s making sure that the medication lists are updated in the EMR and kept current with dates included.

The other piece is documentation with patient safety. What we’re finding is that there are templates that need to be customized to a particular specialty and that there needs to be a system to make sure this information is kept accurate and updated; and there needs to be a system that makes it easier for a practitioner using the EMR to repeat some of the data without necessarily cutting and pasting. We’ve seen patients, when you look at records, who have been pregnant for three years because the note is copied from another visit that says “patient is 8 months pregnant,” and she continues to be 8 months pregnant for at least 3 years.

What were your experiences with the health information exchange and professional liability carrier? We are moving from them to working with a large group practice. The health information exchange didn’t work out because there were so many different EMR systems that they wanted to use, and the adaptability by the vendors is a problem. So, we ended up going with InterMed, out of Portland, ME, and we’re working with them related to their particular system.

How are they able to help you improve patient safety using risk management protocols and other infrastructures? What we’re working with them on is a baseline, which is very important in order to see where they are, and we have a whole patient safety module that we use to look at what they are indeed doing regarding those domains. We ended up focusing in with them on managing patients on anti-coagulation, because that crosses all aspect of patient safety. It’s a systems issue, a communication issue, a handoff issue, a medication issue, and a documentation issue, including such things as patient education.

And what we’re doing with them is actually putting into their system—and this is a work in progress (next year will be better when we finally follow-up on this—a medication piece. When medications are started, we’re working with them to generate a whole process of forms, educational materials, and flags that go into this system so that wherever that patients is being seen, the providers know that patient is on anti-coagulation without relying on the patient, who might be in one of various states of mental states (anxiety, unable to retain all the information they’ve been given) as well as physical.

We’re making sure we have a good history with them, which speaks to the documentation. We’re generating a form to send so the patients know what their responsibilities and rights are, as well as the risk and benefits of the medication so they’re fully informed and partnering with the physician for their care, particularly related to the anti-coagulation.

The testing piece will be in the informed consent so we’ll be able to work with them to track that the patients are complying with their blood work and follow up with them on the lab results. For it to be an active system—some times lab results come in and it’s a passive; they’re somewhere in the system and the physician or provider has to go in and look for them—we’re working with them to make sure there’s an alert system,] so that when those results come in to a centralized area, it’s flagged and they have those results in their face and can make adjustments accordingly.

The other part we’re working with them on is making sure that patients keep their appointments for their lab work—that that also is flagged. Sometimes patients get lost; they’re ill or change their mind or can’t get a ride to the lab, and so patients who go on that same Coumadin dose for a period of time and can actually be at a high risk. Hopefully, we’ll reduce the risk of patient injury and death. We’re very excited about it, and it should be really good for patients.

What factors must a physician look at in evaluating their practice’s current or proposed medical technologies for integrating patient safety and measurable risk reduction strategies?

What each provider should be looking at for patient safety is the responsiveness of their EMR system; it needs to be something they can tweak and change related to changes in practice and best practices, so that as they learn something that someone else is doing—for example the work that we’re doing with the anti-coagulation management at InterMed—they would be able to make those changes. And a lot of times, it’s the big vendor who doesn’t have someone to respond to them in a timely matter. So they develop workarounds that end up defeating the purpose of the EMR.

I think the EMR has to be user-friendly—a system that uses the flags that we talked about, rather than relying on the provider to go in and find the data. Physicians are so busy seeing so many patients that they need to have a system that helps them get the information they need.

Another thing to look at is the use of documentation in the system. Providers should see how easy it is to use check boxes. That relates to the templates they’re using; they need to have customized templates for their particular specialty. My favorite example comes up in pediatrics, if you look at the chart and it’s a boiler plate for an adult in internal medicine and it says the 5 year old libido is in tact, the doctor can’t possibly have checked that. The credibility is at stake. Physicians see it as you point it out to them, and they want to use the EMR because they see the value of it, but they need to make sure it’s meeting their particular needs.

The final thing is checks and balances, and that sort of goes with the tracking system as follow up. That’s something that we as a professional liability insurer really look at; tracking of the lab work, tracking of tests, follow up of the abnormals, tracking and following of patients who don’t keep their appointments—it has to be an active, almost aggressive, system to work with the providers to make sure they’re following their patients as closely as possible.

What key take-away points will attendees of your presentation gain?

Providers need a champion when they’re implementing an EMR system, and I think that’s something that’s consistent no matter with whom you speak. They need someone who is well respected—not necessarily the older physician who is afraid of the changes, because there is a lot of fear of the unknown, or the new, young physician right out of med school who can text with their eyes closed, but someone who has some clinical credibility and can dedicate time to work on it.

We recommend a single EMR system throughout the practice. I mentioned earlier our issues with the health information exchange; that was a major problem, because not everyone was on the same page and not everybody was able to use the same system, and that whole integration of data and the flow of information from the hospital, to the lab, to the provider, to the specialist was really, really a problem.

Physicians need to take time to plan very, very carefully. We recommend that they be very specific about what they want and need and make sure everything is communicated to their vendors. I understand from InterMed that they did a 60-page RFP when they were looking for their EMR system. They did a lot of due-diligence.

EMR users need to continue to test as they go along, correct the errors, get the feedback, and act on it.

The bottom line is to be patient and persistent, physicians who are implementing an EMR system truly will need both. We’ve found that in order to be done right, it has to be done slowly and with all the input from the providers and all the users, and there needs to be someone who is willing to act on it. And they need a vendor that is receptive and responsive to those particular needs.