Quality, Safety, and the Electronic Health Record (EHR)

Abstract

Adoption of electronic health records (EHRs) has increased markedly in response to technology advances, documentation and quality reporting mandates, and regulatory pressures. EHRs have shown promise in supporting quality and safety in surgical specialties through delivering knowledge, standardizing care, measuring compliance, and tracking quality. Evidence from systematic reviews has demonstrated that EHRs can enhance efficiency, improve the quality of surgical documentation, increase guideline adherence, reduce medication errors and adverse drug events, and improve selected clinical outcomes. Artificial intelligence techniques, such as natural language processing and machine learning, have been leveraged within EHRs to identify surgical complications, quality indicators, and safety metrics. Telemedicine and patient portals, within or in combination with EHRs, have enhanced communication between surgeons and patients, offered alternative modalities for the delivery of surgical care, and increased patient satisfaction. Implementation and maintenance of EHRs are complex endeavors, and surgeons should be integral participants in the associated workflow redesign, testing, user education, and ongoing evaluations. Effective health information technology leaders must have expertise in implementation science and management, knowledge of evolving technologies and associated regulations, and awareness of privacy and security threats. Fostering a workforce of surgeon informaticists with formal informatics training and practical clinical experience will be invaluable to surgical communities as they embrace new technologies.