We are forgetting that the EHR and the various IT now being implemented into the healthcare dynamic are simply documentation tools. The computer is not going to save a life. The doctor, nurse, therapist, technician who reads and interprets the documentation within the EHR is the life saving entity.

The hard copy, paper chart never saved a life. Those professional medical clinicians who used the chart to communicate the patient's medical information, tests, diagnosis, orders, procedures and subsequent care are the ones who read the chart, discerned the written word into actionable care and saved the patient's life.

While the EHR is a wonderful TOOL, it does not possess the subjective and objective medical training and experience to evaluate the patient and make crucial health care decisions ongoing or in a code status. The EHR is available to document the required patient information to and through said circumstance/s.

Saving lives is a human to human interaction. Yes, humans have access to various computer technologies that assist and support in that mission, but it the human medical provider and nurse who must document appropriately and read the documented information within the EHR in order to comprise a suitable course of medical action to save the life!

Medical care is conducted by human to human interaction, supported by electronic documentation.

The burden of resolving death from medical errors should not fall largely on health care providers, but on processes and inconsistent support of patient engagement. Rarely are consumers or caregivers consulted to help identify the root cause of these medical errors and it is their families we are harming. I have overlooked the heavy sighs from a nurse when I ask her to change gloves when I've seen her open a computer, respond to a phone call, then begin to insert a central line into my Mom's arm. I have also overlooked a physician's rolling eyes when I ask questions about my husband's surgical procedures. The physicians and hospitals we work with are dependent on multiple stop gaps to help identify system adoption problems.

I've been on the front line helping providers adopt EHR systems and have been largely disappointed by the EHR companies that don't first reach out to the quality improvement folks to see what barriers need to be redesigned first. Instead, implementation becomes a race for market share. But if quality wasn't addressed first, the next best time is now. To reduce medical errors, consumers need to become health care aware. Health care providers must fold consumer and caregiver advocates into health literacy and hospital process redesigns so that families and caregivers can be a helper (i.e. use the patient portal, for example) rather than an annoyance.

1000 a day! Too bad Bloomberg, all those mayors and rest of the Gun Control Crowd don't focus on this topic... We need Mayors Against Medical Mistakes?

Avoidable medical error and hospital acquired infections kill 440,000 patients each year

in US hospitals, the third greatest cause of death in the US after cancer and heart disease. USNews ratings of Cleveland Clinic are contradicted by other independent and government reviews. Modern Healthcare cover story 8 June 2014

(http://bit.ly/1xo0UXK) disclosed "stonewalling" by Cleveland Clinic officials in the CMS investigation of patient harm, patient rights violations, informed consent violations,

alleged double billing, fraudulent credentials, operating room fires injuring patients (http://j.mp/1qYm9fU ) and other egregious violations. Mr. Cosgrove was personally

cited by CMS for his failures. Two of nine CMS investigations found that Cleveland Clinic Urology Department did not have proper credentialing or privileging of staff or residents for use of the da Vinci robot. Healthgrades ranked Cleveland Clinic with the lowest possible score for prostatectomy outcomes. (http://www.healthgrades.com/ho... CMS data for Hospital Acquired Conditions (HACs) gave Cleveland Clinic a score of 8.7 (with 1-10 possible and 10 being the worst.) (Medicare's hospital acquired condition scores for hospitals: (

This score placed Cleveland Clinic in the bottom 7% of hospitals. Leapfrog Group gave the first ever letter grade of “D" to the Cleveland Clinic for patient safety. (http://www.healthleadersmedia.... Cleveland Clinic should spend less effort marketing their "World Class Care" and become more transparent to patients and CMS investigators. One must ask, does USNews have a conflict of interest with the Cleveland Clinic as does the Plain Dealer? –Are there CCF board positions and advertising revenue streams paid to these media giants? What else, but a “quid pro quo" could explain these contradictions? General Motors CEO was held accountable. It is time hospital CEOs also be held accountable.

While I totally agree with Dr. Voltz and I see Scott, with the EHR vendor-Epic's points of view; I also agree whole heartedly with Carolyn Hartley as well. The first thing i told my hospital board of commissioners was our performance would drop on many if not all of our key quality of care initiatives due to the transition to the EHR. I was correct. Quality, as I have discovered after attending several conferences with other facilities, was never invited to the table by the multiple vendors, including my own. Key data important to improving outcomes and monitoring was not readily available due to the push for "meaningful use". What we have discovered in this was a reversal of patient priorities-patient engagement and ability to exchange pertinent patient data between providers WITH EASE were not defined and refined prior to initiation of the nationwide push.

Too many vendors involved in a very broadly defined process has led us to where we are today, we have states who still cannot exchange important information like immunization and syndromic data, electronically. Attention to this type of infrastructure as well as ways to really improve hand-offs should have been the focus of this movement to EHR. If the States and CMS had worked on a way to start with the exchange of that information between their own providers then some of the bugs could have been worked out on the front end and vendors and facilities could have started exchanging that information in stage 1. I have local physicians who still refuse to utilize EHR because there is no easy way to interconnect with other providers without expensive interfaces without having to have a different one built to specifically communicate with each different EHR (at a significant cost for each one).

There is too much burden, at this time, to get this record to be meaningful for the purpose of patient care, safety and engagement. Barscanning has assisted in decreasing medication errors to a point but there's always a work round that someone discovers. EHR progress notes pull in too much data and problem lists that are not pertinent to the patient's current stay or visit, when a patient transitions back to his/her primary provider it takes more time to decipher the records received as the formats are not consistent and are cluttered. We need a simple nomenclature layout that works first for the patient and then their providers to communicate clearly. AS I tell my staff constantly- Patient Care ALWAYS comes first, write it on your scrub pants then enter it in the record. I'd hate for someone to delay my EKG for my AMI so they can plug it into the "system" so it can capture the time in my EMR for that Quality Measure.

Eventually this will become the common way that we do business and the residents that i work with are familiar with EMR but have to learn a new one at each facility they rotate through-safety issue? I think. It takes about 6 months for an individual to become adequate in understanding how to input orders, chart and pull data from an EMR and feel comfortable with it. Think about rotating through a different facility every three months and you get a 1-2 day orieintation on a product before you are let loose to practice in it. I am curious as to how the different facilities wht EMR and Residents are fairing on their various measures related to patient outcomes, i am sure that CPOE rocks.

I don't doubt the numbers went from 100K to 400K. It's the quote "What these numbers say is that every day, a 747, two of them are crashing. Every two months, 9-11 is occurring…" This is 9-11 every three days!!

The whole system is geared towards doing more in less time, whereas in fact, it is well known that the time is the best healer. There is simply too much medical intervention without any regard to the natural history of most of the diseases becuase of medical industrial complex.

There is no question that EMR's are tools in the healthcare system, and not the brains behind treatment, decisions, or the delivery of care. But we can not forget, EMR's are at the center of healthcare delivery as a documentation, order placement, order retrieval tool, and the repository for patient data. It is a tool many depend on for taking care of patients not merely for documentation as suggested by Scott, but instead a tool all healthcare providers are dependent upon for the safe and consistent delivery of care and whose design can affected the entire heathcare system with issues such as alert fatigue, incorrect order delivery, and the free flow of information contained within these data repositories.

There are many issues with the design of EMR's and with the localization of critical patient data. Access to the data, in a format that facilitates the transformation of data into information so accurate and timely decisions can be made and appropriate and correct orders placed for the care of patients. Not withstanding, the ability for physicians and other healthcare providers to interact with information in a uniform way and to share this information with patients so to empower them to share in their care is absent in the current EMR designs.

Most patient data is presented to providers as nested lists of documents or as tabular data displays, often many pages deep, requiring scrolling in multiple directions to view the entirety of an epoch of care which adds to the cognitive burden of providers. Physicians have to

Search for and hold various pieces of data in their mind or develop wor arounds where they take paper notes in the decision making process, something that can be facilitated with better data displays and an understanding of the workflows for those dependant on the data. Finding information contained in different EMR's is even more challenging since there is not one uniform way to access this information and different EMR's store information using different taxonomies, requiring learning various programs to access the same information or constant switching between different applications to obtain the complete picture of a patients presentation. A perfect example is an outpatient clinic where care was initiated and documentation placed in an ambulatory EMR, and then admitted to a hospital where a quite different in-patient EMR exists for the continued management of care.

Although a paper chart has never saved a patient life, that documentation tool contained information in a sequential, standardized narrative of a provider's thoughts as well as the course of action. The paper chart had developed into a tool that allowed for the communication of complex and evolving patient issues coupled with decisions in a standardized and accessible way. There is no question the information contained in these narratives might have been difficult to read, and there is no question the data contained in the narrative was not accessible to computers for the tracking of quality or billing information.

However, any number of consultants were able to create the story of the patient from the various providers' perspectives by reviewing the progress note flow and the orders that have been entered and taken off by nurses. One can argue this information is or should be contained within the electronic equivalent in the patient chart, the EMR, but there are numerous barriers to extracting information and understanding the flow of patient care. The tabular display of data requires providers looking for patterns to reconstruct the trends in their head as they transition between various layouts and areas of the EMR.

Little in the way of design exists within EMR records to present the information in a formatted and visual display allowing for accurate and timely decisions to be made on the information. The paper-based ICU flow sheet contained a great deal of patient information that was displayed in a format that allowed for a comprehensive view of a patients care over a 24 hour period. Obtaining this view with an EMR today requires multiple mouse clicks and navigation to uncover vital signs, infusion titrations, ventilatory settings and changes over the prior day, fluid input and output, laboratory results, and significant nursing or consultant interactions with the patient.

Navigation of current systems are cumbersome and patient information can be entered into various areas within the EMR depending on where the provider chooses. A single blood glucose value can be entered in at least 4 different areas of the EMR, opening them up for being missed of another provider is not expecting to find the information there.

Not only is the design of the EMR displays problematic, but the entry of information is another challenge that has the potential for patient error. Order entry and administration if the order is also difficult to track in current EMRs. In a prior study by Bates, et al, residents required an additional 44 minutes per day to enter patient orders. The added time and complexity required to place orders opens up providers to forgetting to enter something, or nursing missing to take off something that was ordered.

Nursing has many of the same problems discussed previously with respect to the location of information. Many orders must be competed using fixed forms. There are numerous times in the care of a patient that customized orders need to be placed, or a communication needs to accompany an order to ensure the appropriate order is administered to a patient. This often requires a narrative note to be added to the order. If the order and the narrative note are uncoupled for any reason, the potential for an error looms.

Another issue with order entry is in the overall management of a patient's care. With current EMR's, there is often a decoupling of order entry and clinical documentation. In the pre-EMR workflow, physicians would document issues in the narrative progress note and comment on dealing with abnormal issues along with their decisions and treatment plan. With EMRs, values are entered into the system, in many situations automatically captured from connected patient monitors or laboratory devices. When abnormal values log into the EMR, there is an inability to follow who is aware of these issues, and if they have been addressed. Although the ability to communicate this information to all providers and to document the management of these aberrations, they are not yet part of the EMR system.

My point is there is no question that from one perspective the EMR is a tool and not responsible for the care delivered by the nurses, therapists and physicians. But the EMR is so intermittently intertwined in the care of our patients and the way they capture, present and allow for management of patients is critical to the safe and effective care delivery.

As a physician involved in the clinical care of patients, I understand the issues and am working hard to uncover the issues and potential errors made possible with EMRs. Many physicians are frustrated with EMRs and for the most part it is not that they are resistant to change and the adoption of technology in medicine, especially since there are numerous potential benefits EMRs add to our practices. The frustration comes from the added potential for errors and the difficulty added to our practices with these tools.

I am working hard to communicate the issues physicians have with EMRs and to develop tools and identify those that can fix this problem for the betterment of our patients, and to reduce the errors that result when you add another complex system to an already complex set of processes. There is progress being made an many of the issues raised in this article have solutions, the challenge is to demonstrate these solutions to others and to integrate them into the systems.

The expensive implementation of complex EMRs has taken place supported by the HITECH act, replacement is not the answer. Instead, developing tools that interact with the data contained in these systems like Zoeticx, and designing new entry and communication tools that directly interact with this information can go far to address medical errors while maintaining the benefits touted with EMR implementation.

I think one of the fundamental requirements for any EHR is that it is available at the point of care. This seems not to be well promoted and my fear is we are jeopardizing not only patients but care givers. We must promote best practice and safety and unless we provide access at the point of care who is really responsible for the errors.

We have the most technology in use yet still no impact seen in medical error rate reduction? Perhaps because vendors try to sell technologies into the healthcare market versus solutions to medical issues in need of technical resolution.

I work at RKF Medical and we had a co-worker that went into the hospital for a normal procedure and almost died because he got an infection. That is scary.

Donald, I see your point and perspective/s. I just wanted to add that with the Epic EHR, the one I train nationally, there are key word search panes within the Chart Review, Note Review, Active Order Activities that allow the physician/RN to quickly locate the specific piece of documented information within said note.

Also Epic provides the physician with sequential, concise, comprehensive Smart Tools that have taken the long narrative note and organized the respective note/s into a national standard. Agreed that it will take some time for a nation of doctors to become fluent and completely proficient with the standardized note writing and reading tools, but, at least with Epic EHR applications the Smart Tools, Smart Text, Smart Links, Smart Phrases the notes can be documented appropriately and enable faster documentation and subsequent review.

There are also tabs within each Epic screen shot/page that allow for specific viewing choices. Such as Active Orders, versus Discontinued, or Modified orders. Each Activity opens to a screen with an associated tool bar. That tool bar contains varying Filtering options for each individual clinician to personalize according to their respective needs per their specialty.

Again, I can only speak from the Epic EHR system. I am not fluent on the other EHR systems being used through out the country.

It's no surprise that these mistakes are proliferating with the swift digitialization of the industry and the seemingly slow pace of solution adoptions that providers can use to help mitigate some of the risks associated with medical mistakes. It is comforting to see many more hospitals turning to the use of biometrics for patient identification however as a means to help dramatically reduce errors associated with patient misidentification, no matter what the context - mobile, patient portals, kiosks, etc. Biometrics sure are playing a key role in the fight to at least address some of the errors made through not properly identifying patients.