A sign of the times in the evolution of modern healthcare practice is the prevalence of the electronic health record (EHR). In the past fifty years, technological advances and payer incentives have resulted in a sea of change in healthcare documentation, causing healthcare providers to shift from the historic practice of using paper records to using electronic health records. Healthcare providers navigating the transition from paper to electronic records have encountered many challenges in learning and mastering the efficient and accurate use of EHRs. One challenge with significant and potentially life-or-death consequences to patient health is ensuring that EHRs contain accurate information.
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According to a recent report from Becker’s Healthcare, EHR-related medical malpractice claims have tripled since 2010. Although EHR-related deficiencies are not typically the main reason for medical malpractice claims, they are a significant factor identified as contributing to medical injuries in a growing number of cases. The Becker’s article cites a study by Doctor Company, which indicated that on average in 2010, only seven medical malpractice cases assessed identified EHR errors as a contributing cause to claims; that number rose to an average of 22.5 cases per year in 2017 and 2018.
The types of EHR claims risks in the referenced study most often included systems technology, design, or user-related issues. In one example of a systems technology error, a standard abbreviation was used automatically by the EHR computer program to identify a certain type of drug. This reportedly led to the prescription of the wrong medication to a patient: In an incident referenced in the study, a female patient should have been prescribed “Flonase” nasal spray to treat her sinus infection; however, instead her doctor accidentally prescribed “Flomax,” a medication to treat enlarged prostate, because by entering an abbreviation in the medication order screen for the intended medication in the EHR – the doctor entered “FLO” – the EHR program automatically selected the wrong prescription. The doctor did not notice the error at the time of the prescription order, and the EHR program did not contain a drug alert for gender.
In examples of user-related errors cited in the study, doctors allegedly copied and pasted old, outdated patient progress notes from previous medical appointments into the EHR, rather than entering new notes at each patient appointment. In the cases cited, those user errors allegedly resulted in a lack of follow-up tests and deterioration in patient health. In one instance, a patient died without having received certain follow-up testing appropriate to treat his condition.
Some recommendations for physicians, nurses and advanced medical practice providers in avoiding the risk of a medical malpractice claim or lawsuit by keeping accurate EHRs are as follows:
- Providers should enter new, accurate progress notes in the EHR at every patient encounter. Do not copy and paste old progress notes from previous appointments. If you do use the copy and paste feature of your EHR, do it sparingly: only to describe the patient’s past medical history.
- Providers who notice that EHR “auto-populate” fields are causing errors should contact their IT support staff and EHR vendor to minimize risk of error from that feature.
- Providers should review their own EHR entries carefully to ensure accuracy for every patient encounter.
- Providers should consistently take action to identify, reduce and correct medical errors. They should report any significant medical error or risk of which they become aware to their risk manager or supervisors as soon as possible, whether it involves their own or a potential system error. Taking steps to report and reduce patient risks and harmful outcomes protects patients and providers, and bolsters improvement to the quality of medical care.
Our Georgia and South Carolina business and healthcare law firm provides advice and counsel to healthcare providers, health systems, hospitals, physician practice groups and other medical practice managers and administrators in implementing best practices to reduce the risk of medical malpractice claims and provide high quality patient care. If you have questions about this post, contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, email@example.com. You may learn more about our law firm by visiting www.hamillittle.com.
** Disclaimer: Thoughts shared here do not constitute legal advice. Please consult with an attorney to discuss your legal issue.