When Records Do Not Connect: Medication Safety Risks Hidden in EHR Interoperability Gaps

Pharmacists rely on accurate, up-to-date medication information to ensure safe pharmacotherapy. Despite widespread adoption of electronic health records (EHRs) in the US, significant interoperability gaps persist among hospitals, clinics, and community pharmacies, compromising patient safety.¹ These gaps affect medication reconciliation, order verification, therapeutic monitoring, and transitions of care, all of which are essential pharmacy responsibilities.

High EHR Adoption but Incomplete Interoperability

Nationwide EHR adoption is well established. As of 2021, 96% of US nonfederal acute care hospitals and 78% of office-based physicians use certified EHR systems^2,3; however, adoption does not equate to seamless interoperability. In 2023, only 70% of hospitals performed all 4 key interoperability functions: sending, receiving, finding, and integrating external information.⁴ This indicates that pharmacists often work in environments where technical capability exists, but routine clinical exchange remains incomplete.

For example, community pharmacists face additional challenges because dispensing systems may not directly link to clinical EHRs or statewide health information exchanges. As a result, medication histories frequently remain fragmented, especially during transitions of care.

Medication Reconciliation and Safety Risks

Pharmacists play a leading role in medication reconciliation, an activity that is critically dependent on complete cross-setting medication data. When interoperability gaps exist, pharmacists must rely on manual communication, patient recall, or partial records. Medication-related harm is a major global safety issue. The World Health Organization (WHO) estimates that medication errors cost about $42 billion USD annually, accounting for 1% of the total global health expenditure.^5,6 In response, WHO launched the Medication Without Harm initiative, targeting a 50% reduction in severe, avoidable medication-related harm worldwide.⁶

A systematic review found that pharmacist-led medication reconciliation, combined with computerized provider order entry (CPOE), significantly reduced prescribing and administration errors across adult medical-surgical settings.⁷ These findings are highly relevant, as interoperability failures undermine the completeness of medication lists and the accuracy of reconciliation.

Impact on Order Verification, Clinical Decision Support, and Workflow Burden

Pharmacists depend on timely access to laboratory values, allergy profiles, active medications, and comorbid conditions to verify orders; however, incomplete interoperability limits the accuracy of clinical decision-making. CPOE systems can reduce prescribing errors, but only when the underlying clinical data are complete. Exchanging inadequate and inaccurate data can result in incorrect drug–drug interaction alerts, missed renal dose adjustments, and overlooked duplicate therapies, among other problems that pharmacists must then manually resolve.

Although most workload studies involve physicians, the mechanisms identified apply directly to pharmacy practice. A time-motion study found that health care professionals spent approximately 35% of clinical time on documentation, both before and after structured EHR implementation, raising concerns that system complexity displaces direct patient care.⁸ Pharmacists experience similar burdens when navigating multiple data sources to complete order verification or medication reconciliation tasks.

Further, EHR usability also influences clinician well-being. A national survey of 8705 physicians demonstrated that each 1-point increase in the System Usability Scale score was associated with a 3% lower odds of burnout.⁹ Although the study was only conducted in a cohort of physicians, the relationship between workflow complexity, EHR usability, and cognitive load is directly applicable to pharmacists, who are expected to work around incomplete medication data and inconsistent interoperability.

Transitions of Care: A Persistent Vulnerability

Pharmacists frequently identify medication discrepancies during transitions among hospitals, emergency departments, primary care offices, and community pharmacies. Such discrepancies often result from incomplete or missing medication histories, highlighting the need for thorough documentation during patient transfers.¹⁰

Growing evidence indicates that medication discrepancies during care transitions were linked to interoperability gaps and incomplete electronic information exchange. Fragmented information technology systems limit clinicians’ access to accurate medication lists, directly compromising safety.¹¹ Modeling in England’s National Health Service estimates that interoperable prescription transfer would prevent anywhere from 180,000 to 913,000 medication errors and 4 to 22 deaths annually.¹² Meta-analysis data also show that electronic reconciliation tools reduce unintended discrepancies by about 45%.^13,14

Conclusion

From a pharmacist's perspective, gaps in EHR and failures in interoperability directly impact medication list accuracy, including the safety and reliability of order verification; the efficacy of clinical decision support; the detection and prevention of medication-related harm; pharmacy workflow efficiency and the cognitive load on pharmacists; the quality of patient counseling and medication therapy management services; and care coordination amid transitions of care. Given the scale of measurable medication-related harm—$42 billion annually—and the proven benefits of pharmacist-led interventions, enhancing EHR interoperability is critical to patient safety.

REFERENCES

1. Rajamani G, Diethelm M, Gunderson MA, et al. Crowdsourcing electronic health record improvements at scale across an integrated health care delivery system. Appl Clin Inform. 2023;14(2):356-364. doi:10.1055/s-0043-1767684

2. National trends in hospital and physician adoption of electronic health records. Office of the National Coordinator for Health Information Technology. Updated March 2022. Accessed November 22, 2025. https://www.healthit.gov/data/quickstats/national-trends-hospital-and-physician-adoption-electronic-health-records

3. National Electronic Health Records Survey (NEHRS): 2021 Results. CDC. Updated 2023. Accessed November 22, 2025. https://www.cdc.gov/nchs/nehrs/results/index.html

4. Gabriel MH, Richwine C, Strawley C, Barker W, Everson J. Interoperable exchange of patient health information among US hospitals: 2023. Office of the National Coordinator for Health Information Technology. May 2024. Accessed November 22, 2025. https://www.healthit.gov/data/data-briefs/interoperable-exchange-patient-health-information-among-us-hospitals-2023

5. Medication without harm – global patient safety challenge. World Health Organization. Accessed November 2025. https://www.who.int/initiatives/medication-without-harm

6. Donaldson LJ, Kelley ET, Dhingra-Kumar N, Kieny MP, Sheikh A. Medication without harm: WHO’s third global patient safety challenge. Lancet. 2017;389(10080):1680-1681. doi:10.1016/S0140-6736(17)31047-4

7. Manias E, Kusljic S, Wu A. Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Ther Adv Drug Saf. 2020;11:2042098620968309. doi:10.1177/2042098620968309

8. Joukes E, Abu-Hanna A, Cornet R, de Keizer NF. Time spent on dedicated patient care and documentation tasks before and after the introduction of a structured and standardized electronic health record. Appl Clin Inform. 2018;9(1):46-53. doi:10.1055/s-0037-1615747

9. Melnick ER, Dyrbye LN, Sinsky CA, et al. The association between perceived electronic health record usability and professional burnout among US physicians. Mayo Clin Proc. 2020;95(3):476-487. doi:10.1016/j.mayocp.2019.09.024

10. Naseralallah L, Stewart D, Price M, Paudyal V. Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review. Int J Clin Pharm. 2023;45(6):1359-1377. doi:10.1007/s11096-023-01626-5

11. Manskow US, Kristiansen TT. Challenges faced by health professionals in obtaining correct medication information in the absence of a shared digital medication list. Pharmacy (Basel). 2021;9(1):46. doi:10.3390/pharmacy9010046

12. Camacho EM, Gavan S, Keers RN, Chuter A, Elliott RA. Estimating the impact on patient safety of enabling the digital transfer of patients’ prescription information in the English NHS. BMJ Qual Saf. 2024;33(11):726-737. doi:10.1136/bmjqs-2023-016675

13. Li E, Clarke J, Ashrafian H, Darzi A, Neves AL. The impact of electronic health record interoperability on safety and quality of care in high-income countries: a systematic review. J Med Internet Res. 2022;24(9):e38144. doi:10.2196/38144

14. Mekonnen AB, Abebe TB, McLachlan AJ, Brien JAE. Impact of electronic medication reconciliation interventions on medication discrepancies at hospital transitions: a systematic review and meta-analysis. BMC Med Inform Decis Mak. 2016;16(1):112. doi:10.1186/s12911-016-0353-9