Electronic Health Records: Double-edged swords?
A new study by The Doctors Company analyzed electronic health record (EHR)-related medical malpractice claims that closed between 2010 and 2018, and discovered that the pace of these claims tripled, increasing to an average of 22.5 cases per year in 2017 and 2018. By comparison, an analogous previous study analyzing closed claims during the period from 2007 through 2016 revealed that claims in which EHRs were a factor grew from just 2 during 2007-2009 to 7 during 2010, and to 161 during the period from 2011-2016.
As defined by the Centers for Medicare & Medicaid, the electronic health record (EHR) is an electronic version of a patients medical history, maintained by the provider over time, which may include all of the key administrative clinical data relevant to a patient's care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports; the EHR automates access to information and has the potential to streamline the clinician's workflow. In 2017, more than 90% of hospitals and 80% of physicians’ offices utilized EHRs, and today, the utilization is nearly universal. It is undeniable that EHRs tout numerous and significant benefits, including supporting other care-related activities, improving quality management, quantifying outcomes, and strengthening the relationship between patients and clinicians by enabling providers to make better decisions and provide better care. Nevertheless, the number of medical malpractice claims for errors caused, all or in part, by EHRs have risen significantly during the past 10 years.
2017 Study: Key Findings
While EHRs are not often the primary cause of claims, they do present potential risks from various underlying issues that can engender or give rise to potential malpractice claims. This recent study revealed that EHR-related claims are grouped into system technology and design issues, or user-related issues.
User-related issues decreased 6% over during the period of 2010-2018, and most commonly involved entry of incorrect information, pre-populating or copying and pasting information, and "alert fatigue." The term "alert fatigue" refers to an increasing desensitization by providers to computerized order entry system alert popups, which results in providers ignoring or failing to respond to such warnings; the phenomenon occurs because of the sheer number of alerts, and it is compounded by the fact that the vast majority of alerts generated are clinically inconsequential and can be ignored.
The most frequently seen system technology and design issues, resulting in an 8% increase during 2010-2018, included problems with technology and design issues, lack of integration of hospital EHR systems, and failure or lack of alerts and alarms; notably, failure of drug or clinical decision support issues were present in 50% of the EHR-related claims from July 2014 through December 2016.
With respect to the most common injuries among EHR-related claims, adverse reaction to a medication and death were most prevalent, while diagnosis-related allegations represented nearly one-third of the total. Interestingly, internal medicine, hospital medicine and cardiology showed marked decreases among individual specialties involved in claims; family medicine and nursing also showed some decreases. Conversely, orthopedics, emergency medicine and ob-gyn showed increases in EHR-related claims. Also notable, is the location of the precipitating event for EHR-related claims: the study revealed that events are occurring more frequently in patient rooms and less frequently in hospital clinics/doctors’ offices, ambulatory/day surgery centers, labor and delivery, and emergency rooms; however, hospital clinics and doctors’ offices do remain the most common location for these events.
Risk Mitigation Strategies
Avoid copying and pasting, except when describing the patient’s past medical history. Make sure documentation is relevant, objective, and current.
Review all available data and information prior to treating a patient—injury may result from failure to access or make use of available patient information.
Take care when e-prescribing, which is useful but offers many opportunities for error, to ensure adherence to alert popups and document any actions taken.
While alert fatigue is a real problem, refrain from disabling or overriding alerts in the EHR, as physicians can be liable for failure to follow an alert that could have prevented an adverse event.
Contact your organization’s information technology (IT) department or your vendor if you notice that the auto population feature causes erroneous data to be recorded, or with proposals for modifications to alert popups. If the auto-populated information is incorrect, note it and document the correct information. Also note that even if an error can be traced to a faulty EHR design, vendor contracts often have "hold harmless" clauses that attempt to shift liability onto physicians.
Review your entry after you make a choice from a drop-down menu. Templates with drop-down menus facilitate data entry, but an entry error may be perpetuated elsewhere in the EHR. Erroneous information, once entered into the EHR, is easily perpetuated and recreated; best practice is to review an entry after selecting a drop-down menu choice. Especially susceptible to drop-down menu or template errors are History & Physical and Procedure notes, which often auto-populate from older notes and/or templates.
Relocate the computer so the physician’s back is not to the patient and so the patient can view the screen. Remind the patient that you are listening carefully, even though you may be typing during the appointment, and summarize or read the note to demonstrate you have listened.
Be aware of the constant creation of metadata: all interactions with the EHR are tracked and likely discoverable in litigation.
Be aware of tracking functions within the EHR to facilitate consultation and test results are completed, returned to the ordering provider, and communicated to the patient.
Do not share physician passwords with other staff, and remain vigilant about cybersecurity issues. Staff should not be allowed to use a physician's password to review, update or sign off on lab, imaging or other results, as doing so can result in a physician not seeing pertinent results and/or reports.
While EHR-related claims are quickly increasing in number, they do remain a small percentage of overall claims. Nevertheless, they should remain at the forefront of risk mitigation analysis and procedure because the potential for harm can be substantial. Hospitals, facilities, and practices should have processes in place to monitor EHR issues and prioritize the need for EHR improvements and redesign based on risk.