by Dr. Judith A. Effken, Senior Editor
Dr. Jane Carrington
This column was made possible by an educational grant from
Chamberlain College of Nursing
Effken , J. & Carrington, J. (June, 2011). Communication and the Electronic Health Record: Challenges to Achieving the Meaningful Use Standard. Issues, Impacts and Insights Column. Online Journal of Nursing Informatics (OJNI),15 (2). Available at http://ojni.org/issues/?p=555
It has been well documented that a patient’s safety is threatened when seeking care in our nation’s hospitals. For example, in the Institute of Medicine’s (IOM) report, To Err is Human, of an estimated 34 million individuals who are hospitalized each year, 98,000 (nearly 10 every 15 minutes) die as a result of complication of therapy or ineffective communication.1, 2 Ineffective communication costs US hospitals an estimated $12 billion annually.3 A subsequent IOM report encouraged the use of technology, such as the electronic health record (EHR), to increase communication and quality of health care and thereby, increase patient safety.4 As the IOM Committee on Data Standards for Patient Safety informed the Agency for Health Care and Quality, an EHR contains essential functionalities that could improve patient safety, including electronic communication and connectivity.5 This IOM committee suggested that the EHR can provide for effective communication among health care team members and care partners, such as radiology and laboratory, and connectivity for patients such as those with chronic pathologies who are managed by multiple subspecialty care providers.5
Meaningful Use, as defined by Health and Human Services, provides strong financial incentives for using the EHR in such a way as to increase patient safety.6 Financial reward is now attached to using the EHR to meet the 10 criteria established by the IOM committee, including demonstrating the capability to exchange clinical information electronically among providers. This specific criterion will be measured by performing a minimum standard of at least one test of the EHR’s ability to exchange information.7.
Although it is encouraging that the IOM and Health and Human Services have incorporated communication as a facet of the EHR and meaningful use, challenges to accomplishing this objective remain. As noted earlier, patient safety is threatened by ineffective communication. The criterion for measuring this component of meaningful use suggests that simply having the mechanism to communicate electronically may result in effective communication. Both logic and research challenge this assumption. First, having the means to do something doesn’t mean that it will be done; moreover, a single test case is clearly insufficient evidence of success. Second, having the means to do something doesn’t mean that it will actually be done. From a human factors perspective, for the EHR to function as an effective communication system, the end users (providers) and technology (EHR) must interact to achieve the communication goal. In complex health care environments, this means that the communication system must:
(a) transmit data or information that both transmitters and recipients view as important for safe, quality patient care and
(b) the interface for both transmitter and recipient of the communication must be easy to use within the context of an increasingly fast-paced, turbulent work environment.
A second issue in achieving this particular meaningful use criterion is understanding what effective communication really means. Effective communication requires that a sender transmit a message accurately, that mediating technologies transfers the message accurately, and that the receiver accesses and understands the transmitted message correctly. As Coiera notes, “The message that is sent may not be the message that is received” (p. 37)—and this may occur even if the message is actually transmitted as the sender intended based on the layered protocols incorporated in today’s technology. 8 Because we don’t all know the same things (i.e., share common ground), communication can be challenging at times.8 Ideally, the receiver will also take any action required by the message and the patient will have a better outcome. But the messages communicated by an EHR are likely to be data-oriented, rather than task oriented8 —and health care professionals are nothing if not task oriented. Unless the data pertain to the task at hand and are structured appropriately for the task and the various users, they may well be ignored—or not well understood because the sender and receiver have different tasks. Thus, communication can be a long chain of events that is only partially technology-mediated and is fraught with the potential for a break at any point in the chain. Unfortunately, the criteria described for the EHR and meaningful use do not require verification of communication or its use to improve patient outcomes, instead requiring simply that some specific types of patient information can be shared accurately among providers via technology. Therefore, we believe this criterion for meaningful use falls well short of demonstrating the EHR’s function as a communication system.
We all recognize that verbal communication is more than words. Meaningful verbal communication relies extensively on “context, emphasis, tone, body language, and more”. 9 (p. 64). Nurses’ communication via the EHR is largely limited to words—with perhaps some minimal context (time of the event, persons involved). With more structured input, however, the amount of context may be further reduced.
Recent research using functional MRIs shows that in effective verbal communication speakers and listeners’ spatiotemporal brain activities are actually coupled.10 The listeners’ brain patterns mirrored those of the speakers, but with a short (1-3 sec) time delay. The extent of coupling correlated positively with listeners’ understanding of the speaker’s story. When the same story was either transmitted in Russian or decoupled temporally and spatially, no coupling occurred. Remarkably, the most comprehension took place when brain activity in the listener preceded that of the speaker, suggesting that the listener prepares for (anticipates) the message. The researchers hypothesized that this anticipation not only shows the listener’s engagement, but also may help the listener compensate for noise or ambiguity in the message. The length of the engagement prior to the speaker’s beginning the message correlated positively with the listener’s comprehension of the message. Such neural spatiotemporal coupling is precluded by asynchronous EHR-mediated communication, adding another level of complication to establishing meaningful communication.
Meaningful use provides financial incentives for adoption of the EHR. The EHR was initially developed as an electronic record keeping system, which it does reasonably well. Pretty much any kind of data can now be stored electronically and retrieved accurately—with the caveat that what can be retrieved easily depends critically on whether the data were initially in an appropriate, widely agreed-on, structured format 8. However, much less is known about the effectiveness of the EHR as a communication system. A communication system entails much more than data storage—or even the transfer of data from one point to another. Demonstrating that the EHR is also an effective communication system requires, minimally, verification that the sender’s intended message was received and understood by the appropriate recipient and that the communication actually improved patient outcomes.
From a nursing perspective, the meaningful use standards are a good first step toward using information technology to improve patient care outcomes. However, they are only a first step. Because nurses in many institutions have been reluctant to adopt a common, structured vocabulary, the nursing data in the EHR continue to vary in quality, understandability, and accurate retrieval for studying what interventions led to what outcomes—but even to communicate accurately from one nurse to another. So we have a potential problem with the message itself. The complexity of many of our systems can make both transmitting information and receiving it more difficult than it should be—and that can contribute to data not being transmitted—or not being accessed in a timely manner—or at all.
The meaningful use standards set out clear objectives for the EHR—and should inspire all of us to rethink, not only current technology, but also current practice and how the needed information can be communicated more effectively through the EHR to improve patient care outcomes. Achieving the communication meaningful use standards is not a simple problem and will challenge informatics professionals, clinicians, and researchers. Our patients will not be assured of safe, high quality care without the effective use of communication technology. Using the EHR optimally could help ensure that outcome. Our patients deserve nothing less.
1. Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: The National Academies Press.
2. Spear, S. J. (2005). Fixing health care from the inside, today. Harvard Business Review, 78-91.
3. Agarwal, R., Sands, D. Z., & Schneider, J. D. (2010). Quantifying the economic impact of communication inefficiencies in U.S. hospitals. Journal of Healthcare Management, 55 (4), 265-281.
4. Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press.
5. Institute of Medicine. (2003). Key Capabilities of an electronic health record system: letter report. Washington, DC: National Academies Press.
6. Hogan, S. O., & Kissam, L. M. (2010). Measuring meaningful use. Health Affairs, 29 (4), 601-606. DOI: 10.1377/hlthaff.2009.1023
7. Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. The New England Journal of Medicine, 363(6), 501-504. DOI: 10.1056/NEJMp1006114
8. Coiera, E. (2003). Guide to health informatics (2nd ed.). London: Arnold.
9. Curtin, L. (2011). Quantum nursing III: Connecting on the same wavelength. American Nurse Today, 6(3), 64.
10. Stephens, G. J., Silbert, L. J., & Hasson, U. (2010). Speaker-listener neural coupling underlies successful communication. Proceedings of the National Academy of Science U.S.A. (PNAS), 107(32), 14425-14430.
Dr. Effken is a Professor in the College of Nursing at the University of Arizona. She earned her BA in Psychology from the University of Hartford. her Masters of Science in Nursing Management and PhD in Psychology from the University of Connecticut. She was awarded the Ada Sue Hinshaw Research Award for Significant Work in Improving Healthcare in 2008 and was elected to be a Fellow in the American Academy of Nursing and in the American College of Medical Informatics in 2005.
Dr. Effken’s research interests focus around Design and evaluation of clinical information displays, Human-computer interaction, the Impact of organizational and unit characteristics on staff and patient outcomes, and E-learning. She has worked on DyNADS: A Dynamic Network Analysis Decision Support Tool for Nurse Managers.
Jane M. Carrington, PhD, RN is an Assistant Professor at the College of Nursing, University of Colorado Anschutz Medical Campus
Proofed by Paula Lane.