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Guest Commentator

David Bates, MD, MSc


At a recent gathering of medical malpractice professionals in Boston, Dr. David Bates shared a vision of the next five years of health information and electronic medical records. Dr. Bates is a practicing general internist who has been adding his voice to the patient safety movement since before it was even a movement. His passion has been health information, resulting in more than 600 peer-reviewed papers, and work for the Institute of Medicine and the World Health Organization. Modern Healthcare magazine has recognized Dr. Bates as one of the 100 most powerful individuals in U.S. healthcare for several years. He continues to work on change through his position at Boston’s Brigham and Women’s Hospital as a researcher and now Chief Innovation Officer and Chief of the Division of General Internal Medicine and Primary Care.

Dr. Bates acknowledged to the audience that, even the good stuff from electronic records often comes with bad stuff that needs to be fixed.

BATES: There are lots of good sides to electronic health records.

One of the first benefits you see is improvement in medication safety, and that’s being shown increasingly widely. We just finished a paper that looks at the effects of putting in electronic records on our lab. Our lab is not completely interfaced with the rest of the record. We showed that the lab error rate goes down very substantially.

The turnaround time improves really, really dramatically, and that’s very valuable because, for many lab tests it’s just useful to have the information. You can then take a clinical action.

The third thing is, before we put in the new system, most of our labs were being listed as STAT because providers were just frustrated about how long things were taking, and if you didn’t list it as STAT, then it wouldn’t get done that fast. Now that fraction went way, way down, so those are some very near-term benefits that are appearing.

We have to look some more at how things will turn out and there are lots of things that get better, some things that get worse. There are issues, as you probably know, with wrong patient alerts. That’s one of the things that increases after you put in electronic records, because it is easy to write orders on a different patient than the one you think you’re writing them on.

Dr. Bates was asked how to keep electronic alerts from being so ubiquitous that clinicians override them most of the time.

BATES: We have another grant from AHRQ. We are a Center for Education and Research on Therapeutics. A lot of our focus is on various types of alerts and how people respond to them, and we’ve identified, for example, a set of drug interaction alerts that are really important that everyone should have in every single electronic health record in the country. Those are actually being used now very widely. We identified another set of alerts that are in many electronic records that should not be there, and those should be turned off, and work like that needs to be done for all sorts of the main categories.

We’re just in the process of making a recommendation about which drug allergy alerts to turn off. It’s going to be possible to really make things much, much better in that regard. I do have to say we just implemented EPIC at our place and that basically has resulted in the undoing of many years of good work. And so we’re now going to have to kind of go back, because our override rate is again 95 percent and we got to the point where our override rate was about 1 in 3.

So alert fatigue is a super important problem in this area. Actually in many other areas, we need to tune up the way that we’re doing alerts, for example in intensive care. Most of those warnings are just noise, and they actually probably make care less safe instead of more safe.

And, Dr. Bates shared his vision of how electronic medical records should evolve in ambulatory and primary care.

BATES: Yeah, I think it needs to be really different than it is and, as you probably know, I wrote a healthcare paper about this. But the biggest difference between what it’s like today and what I would like to see it be like is that it really should support team care. We’re trying to take all our practices and make them patient center medical homes and if I’m working with my team, things are still not set up so that we can readily communicate so that we can know what the plan is, so that we can figure out if we got there. That’s something that records need to be able to do, but they’re not yet doing.

There are lots of other things that they should do, like making sure that we have closed loops around our referrals. I’m in the process of working on a paper about that, which is through some work that you supported. All those sorts of things have to happen too, but I think the biggest incremental improvement will be this move to team care, so it won’t just be the doctor thinking about things, but other people will be kind of worrying about making sure the right thing happens too.

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