Electronic Health Records

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 with this product and how does it affect liability claims?

Medical Providers' Reluctance

Physicians complain that they are already overwhelmed by “paperwork” and do not 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 health care provider with an x-ray is presenting a piece of medical information that translates across systems. However, if the same patient presents the provider with EHR rather than an Xray, that may not be true. 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, http://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 Proc2003:269-73.

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 teaches trial advocacy at Harvard Law School.

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 with this product and how does it affect liability claims?

Medical Providers' Reluctance

Physicians complain that they are already overwhelmed by “paperwork” and do not 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 health care provider with an x-ray is presenting a piece of medical information that translates across systems. However, if the same patient presents the provider with EHR rather than an Xray, that may not be true. 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, http://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 Proc2003:269-73.

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 teaches trial advocacy at Harvard Law School.