optimize EHR use and what the risks are from either too much or too little customization. The content of CDS likewise needs adaptation, especially to avoid alert fatigue. Any customization must be done with care so that system upgrades can be accommodated.

What Is the Industry Approach to Managing Change and Customization?

The current industry approach is fragmented; a report sponsored by the Agency for Healthcare Research and Quality describes a wide variety of vendor practices related to usability of systems (McDonnell et al., 2010). Because purchasers must usually customize systems to fit local workflows and regulations, HIS safety depends on a combination of industry and local diligence.

RECOMMENDATIONS

Although current evidence is limited, the presence of HIS appears to contribute to less than 1 percent of total errors in health care settings. However, indirect effects from disruption of workflow are difficult to measure. Further investigation into these issues is needed as soon as possible so that solid evidence can inform the bolus of HIS implementations in hospitals resulting from meaningful use regulations. In addition, expert consensus- based recommendations would be highly useful.

REFERENCES

Chuo, J., and R. W. Hicks. 2008. Computer-related medication errors in neonatal intensive care units. Clinics in Perinatology 35:119-139.

Joint Commission on Accreditation of Healthcare Organizations. 2008. Safely implementing health information and converging technologies. Sentinel Event Alert 42:1-4.

Harrington, L., D. Kennerly, and C. Johnson. 2011. Safety issues related to the electronic medical record (EMR): Synthesis of the literature from the last decade, 2000-2009. Journal of Healthcare Management 56(1):31-44.

Magrabi, F., M.-S. Ong, W. Runciman, and E. Coiera. 2010. An analysis of computer-related patient safety incidents to inform the development of a classification. Journal of the American Medical Informatics Association 17:663-670.

McDonnell, C., K. Werner, and L. Wendel. May, 2010. Electronic health record usability: Vendor practices and perspectives. AHRQ Publication No. 09(10)-0091-3-EF. Rockville, MD: Agency for Healthcare Research and Quality.

Myers, R. B., S. L. Jones, and D. F. Sittig. 2011. Review of reported clinical information system adverse events in U.S. Food and Drug Administration databases. Applied Clinical Informatics 2:63-74.

Santell, J. P., J. G. Kowiatek, R. J. Weber, R. W. Hicks, and C. A. Sirio. 2009. Medication errors resulting from computer entry by nonprescribers. American Journal of Health- System Pharmacists 66:843-853.



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