Chris Subbe: Electronic Health Records

In 2022, the then secretary of state for health and social care Sajid Javid promised investment of 2 billion pounds into digital health and Electronic Health Records (EHRs). Short of the build of new hospitals, EHRs are the single most expensive investment of a healthcare organisation. They dwarf investment into scanners, robotic surgery or any other technology.

Access to the right information at the right time is seen as pivotal to improve quality and safety of care and a key argument for a switch to EHRs. Despite this, the evidence for the clinical impact of EHRs is at best ambiguous: A review of the literature showed very little research has been conducted on safety outcomes outside medication safety and there are more and more reports on burn-out of clinicians using EHRs. While EHRs are meant to speed up workflow, electronic documentation systems are often slower and have given rise to the profession of the ’medical scribe’ in some healthcare systems. While costs of EHRS dwarf most other investment, there is hence little evidence that they provide measurably safer care for patients or contribute to efficiency or satisfaction at work.

Research into the safety of complex technology in high reliability industries outside of medicine is well established: NASA has developed tools that can measure the impact of different user interfaces on cognitive load and performance of operators. Similarly to pilots and astronauts, clinicians have to integrate 100s of safety relevant data items to make decisions about life and death. Unlike pilots and astronauts, the testing of their systems will often not have been conducted in a standardised and transparent manner.

This means that, for example, safety critical data on vital signs including Early Warning Scores is displayed differently in EHRs from different brands. And, as with paper notes, information that is critical for the survival of a patient might be buried by the trivial. Importantly, where user experience of EHRs measured it relates to EHR safety metrics: Hospitals that run EHRs with better safety features have a better user experience. This is not quite the same as saying that their care is safer. This evidence is still lacking.

Given EHRs are the backbone of innovation in most healthcare systems, it would therefore seem imperative to create tool-kits and regulatory frameworks that allow regulators, organisations and teams to measure and compare how EHRs are assisting or hindering care. Human factors and usability analysis of clinical workflows at micro and meso-level should allow clinicians and healthcare organisations to choose the providers with the best products based on objective metrics. The final aim should be to improve effectiveness, efficiency, patient centeredness and safety of care for patients in the NHS.