A Clinician's Report of the Unintended Consequences of Electronic Health Records

ABSTRACT Electronic health records (EHRs) are complex. Clinicians must interact with patient data, order entry, decision support, reporting services, messaging programs, administrative data, and many other services. These services require user input and decision making, known as user interactions, between clinician and the EHR. EHRs have features designed to facilitate users' interactions, such as alerts, reminders, keyboard shortcuts, and mouse click menus. These features can lead to unintended consequences, which combine with user interactions, thus making the EHR complicated and difficult to use. Awareness of user interactions and the unintended consequences will improve EHR design and lead to greater clinician acceptance of EHRs. INTRODUCTION The future of patient charts and information is in the electronic health record (EHR). The world of EHRs is upon us all. Just because we switch from paper to electronic records does not mean it is without its' mishaps. There are a number of things that have changed with electronic implementation of paper charts. Paper charts are a repository of patient information. Clerical, administrative, scheduling, billing, and messaging are not found in paper charts. The advent of the electronic chart frees data from isolated sections, allowing them to be combined into one single chart, the EHR, which not only encompasses patient data, but a myriad of other services that are not always familiar to the clinician. The EHR enables patient data to be combined with other services, thus making it a complete record of the patient. The EHR can contain clerical, administrative, billing and ancillary service information. Labs, x-ray, and diagnostic services can all be included. One of the main benefits of the EHR is a messaging system, where clinicians involved with the patient can be contacted simply by using the integrated messaging system. Clinical decision support (CDS) allows best practice recommendations to be fully integrated with the individual patient, with alerts, reminders and individually tailored recommendations made to clinicians These new services make the transition from a single patient chart to electronic records conceptually difficult for clinicians. Shifting from isolated patient data to a fully-integrated, complex, electronic records system can be difficult to comprehend for technology un-savvy clinicians. Not only does the basic model of a patient chart become fully integrated into other services, but the move from paper to electronic is--in and of itself--difficult as well. A basic understanding of the conceptual (chart) changes is necessary to understand why there are so many unintended consequences when an EHR is designed and implemented. I want to offer a view of the most common unintended consequences found in EHR design. They are divided into two categories, those that are directly related to the EHR and those that are indirectly related to the EHR. These consequences are events that occur as a direct result of EHR features that were originally designed to augment and supplement the EHR, but instead have led to events, such as: * Alert fatigue * Click frustration * Keyboard chaos * Mouse madness * Guessing game (aka Synonyms) * Connect-the-dots There are also a number of system issues that are indirectly related to the EHR; nonetheless, they also lead to unintended consequences, for example: * Security time-outs * Password nonsense * Clerking * Information overload * Visual cues While there are many types of unintended consequences, the focus of this article will be on the direct and indirect items mentioned. Knowing why these events occur can lead to a better understanding as to why clinicians do not always readily embrace the EHR. Unintended consequences can be found in every facet of the EHR, from administrative and billing, to patient care and ancillary services, this article is written from the clinician's perspective. …