Electronic Health Records

System Issues

EHRs often have default values that pre-set medication, dose and delivery. Recently the Patient Safety Authority for the Commonwealth of Pennsylvania analyzed 300 events related to EHR software defaults. Patient Safety Authority, “Pennsylvania Patient Safety Authority Examines Electronic Health Record Errors Related to Default Values, Sept. 5, 2013, bit.ly/QElt0u. Of the 341 reported errors, 200 were wrong-time errors, 71 were dose errors and 28 were inappropriate use of an automated stopping function. According to the study's authors, “Many of these reports also showed a source of erroneous data and the three most commonly reported sources were failure to change a default value, user-entered values being overwritten by the system and failure to completely enter information which caused the system to insert information into blank parameters.”

Sometimes a computer could not accept the change even if the provider had made it. Drop-down menus and “copy and paste” options can perpetuate errors. In one example, a resident copied and pasted the admitting note on four consecutive days of a hospitalization; the patient never received the medication intended even though it was part of the care plan. The error was discovered when the patient required readmission due to a complication caused by not having received the ordered medication. Hersy W, Copy and Paste, WebM&M 2007 Jul-Aug (cited 2010 May 18). Available at http://1.usa.gov/1nhsCCj.

Documentation errors have always been an issue, but now with the EHRs, it is easier to make one with a poor keystroke and then replicate it many times over. And it is easier for providers to “rely on previously recorded patient histories, test results and clinical findings rather than collect new information.” Hammond, KW, Helbig ST et. al., “Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting And Dulplications,” AMIA Annu Symp Proc 2003:269-73.

Malpractice and Malpractice Claims: Are EHRs a Help?

Despite the potential risks of EHRs, they are here to stay. There are reasons that physicians may want to adopt them, but defending a malpractice suit is not at the top of the list. Rather, when surveyed, physicians have focused on the potential benefits of timely access to records, better quality of care and better documentation. Terry, Ken, “Will an EHR Affect Your Malpractice Risk?” J Medical Economics ; Vol 84, Issue 13, p 55-558. July 6, 2007. Physicians may be right in their emphasis on patient care as a benefit of EHRs, but it's possible that they may also lead to fewer lawsuits and fewer paid claims.

An early study of closed claims at a malpractice insurer found that 6% of EHR users had a paid claim, while 10% of other insureds had one, although when adjusted for other factors the difference was not statistically significant. Virapongse Anunta, Bates David, et. al., “Electronic Health Records and Malpractice Claims in Office Practice,” Arch Intern Med Vol 168 (NO. 21), Nov. 24, 2008. A more recent study was more positive in terms of an EHR's value in medical malpractice claims. Quinn, Mariah, Kats Allyson et. al, “The Relationship Between Electronic Health Records and Malpractice Claims,” Arch Intern Med . Vol 172 (no 15), Aug. 13/27, 2012 at p. 1187. Providers in this study using an EHR were one-sixth as likely to have had a malpractice claim lodged against them during the study period.

The authors stated: “Our findings suggest that a reduction in errors is likely responsible for at least a component of this associate, since the absolute rate of claims was lower post-EHR adoption. ' While this study includes only a small number of post-EHR claims, it suggests that the implementation of EHRs may reduce malpractice claims, and at the least, appears not to increase claims as providers adapt to using EHRs.”

Why would providers using EHRs be less likely to be sued? In a national survey of physicians using EHRs that met the “meaningful use” criteria, adopters found that electronic prescribing saves time, laboratory results are available sooner and records are more readily available at the point of care; all of these things allow them to provide better patient care. Supra at fn 6.

Kaiser Permanente, a large integrated system in California, is looking at specific links between EHRs and improved patient care. It found that EHR-based screening for abdominal aortic aneurysms (where rupture has a 50% mortality rate) cut the number of unscreened at-risk men by more than half after an alert system in the EHR was implemented. Hye, Robert, Smith, Andrea E. et al, “Leveraging the Electronic Medical Record to Implement an Abdominal Aortic Aneurysm Screening Program,” J Vasc Surg (in press). The system also found a 5.5% reduction in ER visits and a 5.2% reduction in hospitalizations for diabetic patients after the implementation of electronic records.

The coordination of care provided concrete results. Reed, Mary, Huang, Jie et al., “Implementation of an Outpatient Electronic Health Record and Emergency Department Visits, Hospitalizations, and Office Visits Among Patients with Diabetes,” JAMA Vol 310 (no 10), Sept 11, 2013.

Conclusion

EHRs are on their way to becoming the standard of care in the United States and around the world. Stanberry, Kurt, “US and Global Efforts to Expand the Use of Electronic Health Records,” Records Management Journal Vol 21 (no 3), 2011. During any major change or adoption of new practices, there is always a period of flux and shifting ground. As we continue to move to an EHR model of care, additional data will become available, and systems can adjust to be more effective.

The delivery of medical care will always be, at its essence, a human to human interaction, even if supported and filtered through technology. The potential for errors will always exist, but EHRs, especially as the technology and its integration improve, still offer the opportunities for more benefits to patients. Benefits to patient safety should lead to fewer malpractice claims.

Linda S. Crawford, a member of this newsletter's Board of Editors, teaches trial advocacy at Harvard Law School and consults with witnesses on research-based effectiveness at deposition and trial.

Patients who remain in an integrated Electronic Health Record (EHR) system benefit from better access to integrated medical information across specialties and locations. However, full benefits are not seen in all cases where such systems have been implemented. What might be causing the problem?

Medical Providers' Reluctance

Physicians complain that they are already overwhelmed by “paperwork” and don't need to learn another system's EHR when they already struggle to cope with their own. But the consequence of such an attitude is to risk miscommunication or misunderstanding, both of which can affect the proper care of the patient. A patient who presents to a subsequent treater with an x-ray is presenting a piece of medical information that translates across systems. That may not be true with an EHR that the same patient brings with him. Using a system that has met the “meaningful use” test should reduce the amount of dissonance between systems, and taking the time to understand the differences in the way the two EHRs are constructed can save trouble in the long run.

System Issues

EHRs often have default values that pre-set medication, dose and delivery. Recently the Patient Safety Authority for the Commonwealth of Pennsylvania analyzed 300 events related to EHR software defaults. Patient Safety Authority, “Pennsylvania Patient Safety Authority Examines Electronic Health Record Errors Related to Default Values, Sept. 5, 2013, bit.ly/QElt0u. Of the 341 reported errors, 200 were wrong-time errors, 71 were dose errors and 28 were inappropriate use of an automated stopping function. According to the study's authors, “Many of these reports also showed a source of erroneous data and the three most commonly reported sources were failure to change a default value, user-entered values being overwritten by the system and failure to completely enter information which caused the system to insert information into blank parameters.”

Sometimes a computer could not accept the change even if the provider had made it. Drop-down menus and “copy and paste” options can perpetuate errors. In one example, a resident copied and pasted the admitting note on four consecutive days of a hospitalization; the patient never received the medication intended even though it was part of the care plan. The error was discovered when the patient required readmission due to a complication caused by not having received the ordered medication. Hersy W, Copy and Paste, WebM&M 2007 Jul-Aug (cited 2010 May 18). Available at http://1.usa.gov/1nhsCCj.

Documentation errors have always been an issue, but now with the EHRs, it is easier to make one with a poor keystroke and then replicate it many times over. And it is easier for providers to “rely on previously recorded patient histories, test results and clinical findings rather than collect new information.” Hammond, KW, Helbig ST et. al., “Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting And Dulplications,” AMIA Annu Symp Proc 2003:269-73.

Malpractice and Malpractice Claims: Are EHRs a Help?

Despite the potential risks of EHRs, they are here to stay. There are reasons that physicians may want to adopt them, but defending a malpractice suit is not at the top of the list. Rather, when surveyed, physicians have focused on the potential benefits of timely access to records, better quality of care and better documentation. Terry, Ken, “Will an EHR Affect Your Malpractice Risk?” J Medical Economics ; Vol 84, Issue 13, p 55-558. July 6, 2007. Physicians may be right in their emphasis on patient care as a benefit of EHRs, but it's possible that they may also lead to fewer lawsuits and fewer paid claims.

An early study of closed claims at a malpractice insurer found that 6% of EHR users had a paid claim, while 10% of other insureds had one, although when adjusted for other factors the difference was not statistically significant. Virapongse Anunta, Bates David, et. al., “Electronic Health Records and Malpractice Claims in Office Practice,” Arch Intern Med Vol 168 (NO. 21), Nov. 24, 2008. A more recent study was more positive in terms of an EHR's value in medical malpractice claims. Quinn, Mariah, Kats Allyson et. al, “The Relationship Between Electronic Health Records and Malpractice Claims,” Arch Intern Med . Vol 172 (no 15), Aug. 13/27, 2012 at p. 1187. Providers in this study using an EHR were one-sixth as likely to have had a malpractice claim lodged against them during the study period.

The authors stated: “Our findings suggest that a reduction in errors is likely responsible for at least a component of this associate, since the absolute rate of claims was lower post-EHR adoption. ' While this study includes only a small number of post-EHR claims, it suggests that the implementation of EHRs may reduce malpractice claims, and at the least, appears not to increase claims as providers adapt to using EHRs.”

Why would providers using EHRs be less likely to be sued? In a national survey of physicians using EHRs that met the “meaningful use” criteria, adopters found that electronic prescribing saves time, laboratory results are available sooner and records are more readily available at the point of care; all of these things allow them to provide better patient care. Supra at fn 6.

Kaiser Permanente, a large integrated system in California, is looking at specific links between EHRs and improved patient care. It found that EHR-based screening for abdominal aortic aneurysms (where rupture has a 50% mortality rate) cut the number of unscreened at-risk men by more than half after an alert system in the EHR was implemented. Hye, Robert, Smith, Andrea E. et al, “Leveraging the Electronic Medical Record to Implement an Abdominal Aortic Aneurysm Screening Program,” J Vasc Surg (in press). The system also found a 5.5% reduction in ER visits and a 5.2% reduction in hospitalizations for diabetic patients after the implementation of electronic records.

The coordination of care provided concrete results. Reed, Mary, Huang, Jie et al., “Implementation of an Outpatient Electronic Health Record and Emergency Department Visits, Hospitalizations, and Office Visits Among Patients with Diabetes,” JAMA Vol 310 (no 10), Sept 11, 2013.

Conclusion

EHRs are on their way to becoming the standard of care in the United States and around the world. Stanberry, Kurt, “US and Global Efforts to Expand the Use of Electronic Health Records,” Records Management Journal Vol 21 (no 3), 2011. During any major change or adoption of new practices, there is always a period of flux and shifting ground. As we continue to move to an EHR model of care, additional data will become available, and systems can adjust to be more effective.

The delivery of medical care will always be, at its essence, a human to human interaction, even if supported and filtered through technology. The potential for errors will always exist, but EHRs, especially as the technology and its integration improve, still offer the opportunities for more benefits to patients. Benefits to patient safety should lead to fewer malpractice claims.

Linda S. Crawford, a member of this newsletter's Board of Editors, teaches trial advocacy at Harvard Law School and consults with witnesses on research-based effectiveness at deposition and trial.