Spotlight

1. Spotlight The Hazards of Distraction: Ticking All the EHR Boxes

2. Source and Credits • This presentation is based on the February 2017AHRQ WebM&M Spotlight Case • See the full article at https://psnet.ahrq.gov/webmm • CME credit is available • Commentary by: Anthony C. Easty, PhD, Adjunct Professor, Institute of Biomaterials & Biomedical Engineering, Senior Fellow, Massey College, University of Toronto • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • List the goals of having order sets in the EHR • Describe the evidence supporting the use of order sets in EHRs • Understand how modern digital technology may encourage a superficial analysis of information • Appreciate that order sets may encourage a mechanistic focus that may prevent a deeper consideration of clinical issues • List key principles in the optimal design of order sets

4. Case: Ticking All the EHR Boxes A 55-year-old woman with a history of metastatic cancer was sent to the emergency department (ED) after an MRI of her brain (done for cancer staging) showed a right subdural hematoma with a 5 mm midline shift. The patient was alert and oriented when she arrived in the ED, but she did report falling and hitting her head a few weeks before. Vital signs and neurologic examination were normal. A noncontrast head computed tomography (CT) scan showed the subdural hematoma unchanged when compared to the MRI. A neurosurgeon examined her in the ED and recommended no acute intervention and repeat imaging in one week. The patient was admitted to a hospitalist service for observation.

5. Case: Ticking All the EHR Boxes (2) She did well with no new complaints or complications and was discharged the following afternoon (about 36 hours after admission). She left the hospital and went directly to a previously scheduled positron emission tomography CT scan. On that study, the radiologist noted that the subdural hematoma had enlarged and the midline shift had increased to 11 mm. The patient was readmitted to the same hospital medicine team that had cared for her before. On admission, she was stable with no neurologic complaints and a normal neurologic exam.

6. Case: Ticking All the EHR Boxes (3) The next day, her mental status deteriorated and a repeat CT scan showed an enlarging subdural hematoma. She was taken to the operating room for evacuation of the blood. The surgery was uncomplicated but postoperatively she developed sepsis secondary to hospital-acquired pneumonia. Despite maximal efforts, the sepsis progressed to multi-organ system failure. Care was ultimately withdrawn, and she died peacefully 10 days after admission. The hospital medicine service routinely reviewed all deaths on their service.

7. Case: Ticking All the EHR Boxes (4) In reviewing the death, the case review committee discovered the patient had been given low-molecular-weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis during the first admission. They spoke with the admitting provider for that admission. The provider did not realize she had prescribed the LMWH and stated she certainly didn't intend to prescribe it in light of the subdural hematoma. She stated that she was just "clicking boxes" on the admission order set in the electronic health record (EHR), and that she was used to ordering it as nearly all patients she admitted met criteria for VTE prophylaxis. She did recall being distracted by another complex patient at the time of entering the admission orders.

8. Case: Ticking All the EHR Boxes (5) The case review committee determined that ordering the LMWH was a medical error that may have contributed to the patient's death. They realized there clearly were many benefits to using order sets in the EHR, but wondered about the risks associated with order sets and how best to balance the risks and benefits.

9. Background: Use of Checklists • In many industries, checklists have become routine • Aviation is a good example • A preflight checklist is mandatory before takeoff • The purpose of the checklist is to ensure that no important tasks are forgotten • Failure to conduct a preflight checklist is often a major contributor to aircraft accidents

10. Background: Order Sets in Medicine • Order sets are used as a type of checklist, aggregating orders or steps for a given condition in a single location • Order sets are very common in modern EHRs • Their goals include • Ensuring that all relevant tests and interventions are ordered and that every step in a diagnostic or treatment pathway is followed • Collection of vital signs • Ordering medications • Guiding providers to best practices

11. Evidence Supporting Order Sets • Order sets have resulted in improved outcomes such as reduced mortality, readmissions, and length of stay • Given that it is difficult for any provider to remember every step involved in diagnosis and treatment, they have been widely adopted • Now applied in many areas of health care • The American Academy of Family Physicians has published 30 standardized hospital admission orders, covering a very wide range of conditions

12. Utility of Order Sets in Clinical Care • Key differences between order sets in aviation and health care • In aviation (e.g., preflight checklist), all items must be completed (i.e., "checked" prior to takeoff) • Order sets, on the other hand, contain a series of options that might be selected • All of the orders should not necessarily be followed without exception

13. Utility of Order Sets in Clinical Care (2) • This difference is necessary as each patient is unique and can present with a wide range of symptoms • Most clinicians realize this and thus usually choose only those order set items that are appropriate for each patient • Yet, using order sets may have unintended negative consequences for patients

14. Limits of Order Sets • One study showed order sets reduced errors in chemotherapy from 30.6% with handwritten orders to 2.2% with order sets in the EHR • However, the order set did not reduce errors completely • Users may cede judgment to an EHR order set, assuming its computerized format signals • The appearance of infallibility and correctness • That all listed interventions in an order set are desirable

15. Information Processing • Some have argued that the easy access of information on the Internet and the ability to move from topic to topic has impacted how humans process information • May take in information in a swift stream but often at a superficial level • May be losing the ability to read and think in depth about an issue • May tend to skim digital material rather than reading it and picking out the most salient points to use

16. Information Processing and the EHR • Most modern EHRs have easy access to information and allow providers to quickly move from one task to the next • Easy to imagine health care providers consequently only considering clinical issues superficially • In this case, the admitting provider stated VTE prophylaxis was standard for most patients and she was distracted at the time • Her "slip" may be grounded in her day-to-day experience with the facility of the Internet, compounded by distraction

17. Failure of Checklists and Prompts • Cautions and prompts may not prevent providers from making errors • In a simulation study, a caution statement was inserted at the end of an order set • This alert did not impact rates of error detection • Clinicians seemed to stay in a mechanistic, task-associated mode and did not apply abstract or clinical thinking • Systems and checklists may need to have other ways to support and encourage deeper abstract thought

18. Benefits and Risks of Checklists • Checklists clearly play an important role in modern health care • Help ensure tasks are completed, facilitate efficient workflow, and can guide best practices • Yet, checklists can encourage providers to automatically accept the suggested items in the checklist • If the usual practice for most patients is to "check all the boxes," then it is less likely providers will deviate even when appropriate

19. Designing Checklists & Order Sets • Order sets offer many benefits to outcomes in health care and steps can be taken to optimize their design • In this case, a sensible redesign might be to separate the current lengthy order set such that essential items are prominent and optional items are clearly delineated, prompting users to consider whether these optional items are necessary on a case-by-case basis • Such redesign should be simulation tested to ensure that it will be used safely and effectively

20. Take-Home Points • Checklists and order sets have become commonplace in electronic health record systems, covering a range of diagnostic tests and therapeutic interventions • Users tend to follow all elements of an order set or checklist due to an intrinsic bias to accept the options that the system is offering them, particularly when they are busy and the default setting of checking all the boxes is usually correct

21. Take-Home Points (2) • System designers and implementers need to be aware of the propensity to "tick all the boxes," and should design groupings of lists that are intrinsically safe for all situations, recognizing that users tend not to apply critical thinking when presented with a series of boxes to tick • Published guidelines on the development of standard order sets should be followed