Comprehensive, accurate information in the electronic health record (EHR) is crucial to ensure proper diagnosis and continuity in care, as every medical transcription company knows. In fact, reliable EHR-integrated medical transcription services go a long way in preventing documentation errors that can cause medical misdiagnoses and medical mistakes. Physicians need to be aware of EHR-related errors that can lead to malpractice lawsuits and how to prevent them.
According to a Physicians Practice report published in June 2017, studies show that while EHRs are not the primary reason for medical malpractice suits, they were a contributory factor. Keith Klein, MD, a practicing physician in internal medicine and nephrology and clinical professor of medicine at the David Geffen School of Medicine at UCLA points out that for some provider organizations, an EHR-related catastrophe can cost millions. Klein points out that ongoing research by medical malpractice insurer The Doctors Company shows an increased number of lawsuits related to EHRs. Here are the main malpractice errors that can result from EHR use:
- Careless use of templates and copy-paste functionality: EHR data fields should be filled out afresh at each encounter and not copy-pasted from prior progress notes. Copying and pasting can save time, but physicians should make sure that this does not compromise important, new information and lead to incorrect data that will affect patient care. In a 2016 Medical Economics report, Jeffrey Kagan, MD, a Newington, Connecticut-based internist who reviews malpractice cases for lawyers and insurance companies advises, “While using templates can be helpful, you have to make sure they’re individual to that patient and that particular visit”.
Physicians need to be mindful of preventing the following mistakes while using EHR templates and copy-paste:
- Lack of individualized patient records
- Confusion in gender identity
- Note bloat at each encounter (this could indicate that the records were enhanced by the computer)
- Records with several blanks
- Recurring typos and spacing errors
- Sequential use of similar phrases
To avoid these issues that lead to malpractice suits, physicians should update notes at each encounter.
- Misuse of drop-down menus and auto-complete tool: EHRs support capture of information from drop-down menus. This can make the user click on the wrong item in the menu such as the wrong symptom. Moreover, the use of these menus can lead to structured information, which will interfere with the creation of a rational narrative. Overuse of the auto-complete tool can also lead to lack of data integrity. Using free text to record individualized information about patients can prevent these problems.
- Allowing EHR data entry to affect physician-patient communication: The Medical Economics report cites an internist as saying that patients sue physicians when they feel disrespected and that physicians aren’t paying attention to them. Physicians need to pay attention to the patient at the encounter and maintain eye contact. He recommends that providers abbreviate their findings and update the record with their findings later.
Practical alternatives include having a scribe in the room or outsourcing clinical documentation tasks to an experienced medical transcription company.
- Meta data and ignoring EHR alerts: Ignoring EHR alarms/alerts has been connected to patient harm. In a medical malpractice trial, metadata – the data that can help analyze or interpret clinical information within the EHR – is crucial. Metadata reveals the alerts the physician saw while documenting care in the EHR as well as when the patient’s record was accessed, and how the information was presented. There can be prior versions of the patient record if the physician dictates a report and then modifies a transcription error in the record. This is fodder for the plaintiff’s attorney. The solution is to flag the amended EHR record to indicate that it has been corrected. Also, the physician can include a narrative entry in the medical record statement, clearly documenting the original error and the correction for future reference. The key lies in ensuring that the patient record reflects that chart in a usable manner and does not get distorted when it is examined by a third party.
Legal experts say that more than timestamps, physicians should pay attention to all alerts that come up and take time to review the patient’s lab reports. When data is being entered in the EHR, alerts may appear if there is a problem with medication dosage or drug-drug interaction. Physicians may get annoyed with frequent alerts and turn them off. This can lead to missing a potential problem. Therefore, physicians should never ignore these prompts.
- Missing information: Another reason why EHRs can lead to a malpractice suit is an interface breakdown due to poor technology design. For instance, the EHR may fail to display a test result that the physician needs to make a proper diagnosis. The reason could be that the system did not route the information properly.
Medical malpractice insurance provider The Doctor’s Company reports that it closed almost 100 claims between January 2007 and June 2014 in which EHRs were a contributing factor. Up to 97 claims were for diagnosis-related errors, followed by medication-related errors, with the wrong medication, the wrong dose, or improper medication management given to the patient. Northbay Business Journal suggests the following strategies to avoid such EHR-related errors:
- Review all available patient information
- Heed and reconcile drug interaction alerts
- Pay attention to warnings, reminders, and established practice guidelines
- Don’t copy-paste indiscriminately from progress notes
- Make sure that documentation reflects the patient’s condition by using templates correctly
- Don’t let EHR data entry affect communication with the patient
- Choose a well-designed EHR
- Understand that all EHR-interactions are time-tracked and discoverable
- Adhere to HIPAA regulations related to confidentiality of personal health information
- Comply with federal and state record retention laws before shredding old records and scanning or entering paper records into the EHR
It is reported that medical specialties most involved in EHR-related claims were primary care, family practice, obstetrics and gynecology, surgical specialties (other than cardiac surgery), nursing, radiology, anesthesiology, general surgery, and internal medicine specialties such as cardiology, hospitalist, oncology, and gastroenterology. Medical transcription companies provide EHR-integrated documentation for all of these specialties. Partnering with a reliable service provider can help minimize the risk of electronic health record related malpractice suits.