report. Of their 43 references, we identified 37 that were relevant to the scope of this article. We analyzed the bibliographies of these selected papers and performed a reverse bibliography search on the articles deemed most relevant and published since 2000. In total, we identified more than 100 sources relevant to the scope of this report. We then targeted topics for which published evidence was lacking and conducted several interviews with experts to help fill the knowledge gaps.

RESULTS

What Are the Risks of Health Information Systems That Arise from Workflow and Related Issues?

We found seven publications (Chuo and Hicks, 2008; Joint Commission on Accreditation of Healthcare Organizations, 2008; Magrabi et al., 2010; Myers et al., 2011; Santell et al., 2009; Walsh et al., 2006; Zhan et al., 2006) presenting results of assessments of e-iatrogenic risk. All are studies of large databases of reported errors, and they consistently indicate low levels of HIS-related risk, less than 1 percent of all errors. All point to the need for human diligence when using HIS. Specifically, they indicate that HIS-related errors are due to inadequate staffing levels, lack of user experience, mislabeled bar-codes on medications, human distraction, inaccurate data entry, system downtime, and missing data.

How Have Organizations Acted to Implement Health Information Systems Safely?

Prior to implementation, health care organizations can mitigate risk. There is a large literature base devoted to the risks inherent in commercial EHR systems, and also warnings about their impact on workflow. Many publications offer guidance to hospitals about assessing workflow, selecting systems for purchase, conducting simulation tests, training, and other mechanisms for ensuring safe HIS implementation. Numerous publications exist to guide the implementation process itself, but there are also several pointing to the risks of rapid implementation without appropriate preparation. Finally, after implementation, continuous monitoring and improvement can mitigate safety risks.

What Are the Impacts of Customization on Safety?

The literature indicates that customization of the EHR to fit local situations seems to be necessary for many reasons, but there is scant research on how much customization or what form of customization is needed to



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