Providing Evidence and Developing a Toolkit to Accelerate the Adoption of Patient Photographs in Electronic Health Records (New York)

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Leveraging Health IT to Test Solutions That Are Replicable, Scalable, and Improve Patient Safety


“Studies like that by Adelman and colleagues point the way to the creation of a digital learning health care system, in which the results of the interactions between clinicians (and, increasingly, patients and families) and the EHR are analyzed to help guide the strategies that lead to the highest value and most satisfying care. Having spent tens of billions of dollars digitating the health care system, it is essential to take advantage of the unique capacity of digital tools to allow clinicians and health care systems to learn from every click.” -editorial by Drs. Wachter, Murray, and Adler-Milstein4

Wrong-patient errors can affect any patient in any healthcare setting for a variety of reasons.

Dr. Jason Adelman, named as one of 50 experts leading the field of patient safety in 2018 by Becker’s Hospital Review,2 has led multiple AHRQ Health IT-funded research efforts centered on health IT safety. The research of Dr. Adelman, Executive Director of Patient Safety Research at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, is widespread and being replicated by other organizations. Dr. Adelman is part of the ECRI Patient Safety Collaborative, where he is advising several hospitals on how to implement the Wrong-Patient Retract-and-Reorder (RAR) Measure that he developed to evaluate the frequency of wrong-patient errors that occur through CPOE systems. When a clinician places an order, then cancels the order and places the same order for a different patient within the next 10 minutes, the measure flags it as a wrong-patient RAR event. While capturing the instance of retracting and reordering mistakes does not correct or prevent errors, it provides the facility with information to discover error trends along with opportunities to intercept processes that lead to such errors. Using such data as evidence of the CPOE’s potential impact on patient safety, decision makers can factor RAR measures in choosing one health IT design over another.

Having multiple EHRs open simultaneously does not increase wrong-patient orders.

“Placing orders on the wrong patient should never happen. Yet, human error is very common in the healthcare environment. Healthcare is inherently complex and heavily reliant on people rather than technology to protect patients from harm. It will likely take a multi-pronged health IT approach to prevent these types of errors.”
- Dr. Jason Adelman

Dr. Adelman’s AHRQ Health IT-funded research found that restricting clinicians to having one EHR record open at a time did not significantly reduce the rate of wrong-patient order errors compared with allowing up to four records to be open concurrently. His work did not support the ONC and Joint Commission recommendation that EHR systems should only allow one record to be displayed at a time. In the study, published in the May 14, 2019 issue of JAMA,3 using the RAR measure, Dr. Adelman and his team compared the risk of wrong-patient orders while accessing one versus four records open in a variety of clinical settings, including hospitals, EDs, and outpatient facilities. While no differences in wrong-patient orders were observed between those clinician groups, there was considerable variation in the frequency of errors in different clinical settings. The rate of wrong-patient order errors was lowest in outpatient settings, where physicians may care for one patient at a time. The highest rates, meanwhile, were seen in inpatient critical care and obstetrics units, which reflected differences in workflows and number of patients being cared for simultaneously, researchers noted. The research offers insights for healthcare systems that are trying to balance patient safety with the needs of busy clinicians who need tools for efficient workflow.

The right patient, right dose, right medication, right route, and right frequency.

The Health IT Program has also funded Dr. Adelman to extend research on RAR, to validate and evaluate the reliability of RAR using a different EHR system, so it can be implemented and may advance interventions to prevent these serious and complicated safety issues. The intent is to develop health IT measures that identify deviations from the Five Rights of Medication Safety: right patient, right dose, right medication, right route, and right frequency.

Use of photographs to prevent errors.

An additional Adelman-led, AHRQ-funded study is assessing the effectiveness of using patient photographs as an additional identifier in the EHR system to avoid wrong-patient errors when using CPOE systems. The research team will conduct a randomized controlled trial of wrong-patient error rates between systems with patient photos and without. Ultimately, the team plans to develop a toolkit with guidance to help other health systems in implementing patient photos in EHR systems.

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Project Details - Ongoing


Placing orders on the wrong patient in electronic health records (EHRs) is a significant health information technology (IT) safety challenge that healthcare organizations face today. To prevent these errors, the Office of the National Coordinator for Health IT “SAFER Guide” recommends displaying patient photographs in EHRs. However, only 20 percent of hospitals have adopted this practice, citing a lack of evidence and implementation challenges as major barriers. To date, only weak evidence exists to support the adoption of patient photographs in EHRs.

This study will evaluate the effectiveness of displaying patient photos in EHR systems to prevent wrong-patient errors when using computerized provider order entry systems. Investigators from Columbia University Medical Center and Johns Hopkins Medicine will collaborate with the ECRI Institute’s Partnership for Health IT Patient Safety and an expert advisory panel of patient safety leaders to produce rigorous results across multiple settings.

The specific aims of the project are as follows:

  • Provide rigorous evidence for the efficacy of displaying patient photographs in EHRs. 
  • Identify factors that impact the effectiveness of patient photographs on the frequency of wrong-patient orders, including characteristics of providers, patients, and orders. 
  • Demonstrate generalizability using different EHR systems to evaluate the effectiveness of patient photographs for reducing the frequency of wrong-patient orders across sites and EHR systems. 
  • Provide implementation guidance for displaying patient photographs in EHRs. 
  • Examine user perceptions and experience of patient photographs in the different EHR systems, including staff, providers, and patients. 

Researchers will conduct a multisite, cluster, randomized controlled trial in which providers are randomly assigned to view order screens with or without a patient photograph to determine efficacy. To address concerns about implementation, the study team will develop a Health IT Safety Toolkit, “Implementing Patient Photographs in EHR Systems” to provide guidance for healthcare organizations to adopt patient photographs in their EHR systems. This project has the potential to provide healthcare systems with the rationale and resources to accelerate adoption of patient photographs in their EHRs, and to provide patient safety and regulatory bodies with the evidence needed to require the use of patient photographs in EHRs.