Electronic health records can increase malpractice risks

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Widespread use of the electronic health record (EHR) in medical practices may be contributing to more errors and malpractice liability, according to a recent report by The Doctors Company, a Napa-based medical malpractice insurance company.

The Doctor’s Company closed almost 100 claims between January 2007 and June 2014 in which EHRs were a contributing factor. The top allegation among the 97 claims was for diagnosis-related errors, followed by medication-related errors, with the wrong medication, the wrong dose, or improper medication management given to the patient.

“It takes 4-5 years from the time a claim is filed until it is resolved one way or another. The study, tracking EHR errors, saw very few claims at the beginning, the speculation being that these kinds of malpractice risks are increasing,” said Denise Moore, public relations director at the Company, which is the nation’s largest doctor-owned medical malpractice insurer, with 78,000 members and $4.3 billion in assets.

From 2007-2010, two claims were closed in which the EHR was a contributing factor. In 2013 that number had increased to 28, and 26 claims were closed in the first two quarters of 2014.

“Shortly after electronic health records began to be widely adopted, The Doctors Company and other medical professional liability insurers became aware of their potential liability risks. We anticipated that EHRs would become a contributing factor in medical liability claims,” Doctor’s Group Medical Director David B. Troxel wrote in the report.

From 2008-2013, the adoption of EHR systems in the U.S. increased more than five-fold in non-federal acute care hospitals, according to the Office of the National Coordination for Health Information Technology. In 2008, 9 percent of hospitals had adopted an EHR system. By 2013, 93 percent of hospitals had adopted EHR technology.

Contributing factors in the The Doctor’s Company malpractice claims were both human error and technology issues.

The top user factors included data entry errors; health records tracked in multiple formats and stored in multiple places; conversion from paper to digital files; copying and pasting data without modification; and lack of EHR training and education.

The most EHR claim events occurred in a hospital clinic or doctor’s office, at 43 percent, followed by ambulatory or day surgery center, a patient’s room, the operating room, emergency room, labor and delivery, radiology and imaging, and dentistry and oral surgery.

In one case, a toddler returned from a country where tuberculosis was prevalent, and was taken to the doctor with symptoms of fever, rash, and fussiness. The physician considered the cause was an insect bite or flu and treated the child with fluids, antibiotics, and flu medication. His office EHR note indicated there was “no tuberculosis exposure.” During subsequent office visits, the doctor copied and pasted this information, without a revision to note travel to a country with endemic tuberculosis. Two months later, the child was diagnosed in the emergency room with tuberculous meningitis. He had permanent and severe cognitive defects.

Technology associated with electronic records were also contributing factors in the claims. These included a failure of system designs, such as outdated templates; systems unable to communicate with each other; system failure, including electronic data routing; and insufficient scope or lack of area for documentation.

In another case, a patient was seen by her physician for pain management with trigger point injections of opioids. The physician ordered morphine sulfate (MS) at 15 mg every eight hours. In the EHR, the drop-down menu offered MS 15 mg followed by MS 200 mg. The physician inadvertently selected MS 200 mg and did not recheck before completing the order. The patient filled the prescription, took one MS along with Xanax, and developed slurred speech, resulting in an emergency room visit with overnight observation.

The medical specialties that were most involved in EHR-related claims were internal medicine specialties—cardiology, hospitalist, oncology, gastroenterology—primary care, family practice, obstetrics and gynecology, surgical specialties (other than cardiac surgery), nursing, radiology, anesthesiology, and general surgery.

EHRs also facilitate e-prescribing—which also creates exposure to community medication histories where drug-drug interactions are time-consuming to trace. For example, a doctor renews a medication and her e-prescribing program sends an alert advising her that it could interact with another drug the patient is taking. Because she did not prescribe that drug, her office will have to contact the patient to find out who the other prescribing physician is. She will then have to contact the other doctor to discuss which drug will be discontinued or changed. If failure to do so results in patient injury from a drug interaction, she may be liable.

Tips to avoid EHR errors

• Review all available patient information. Doctors are responsible for the information they can reasonably access.

• If using e-prescribing, be aware of the patient’s entire inpatient and outpatient medication history. Reconcile any drug interaction alerts received.

• Don’t ignore, override, or disable alerts, warnings, reminders, and embedded practice guidelines.

• Think twice before copying and pasting information from prior progress notes. This often results in lengthy over-documentation that obscures important, new information and propagates incorrect information—and compromises patient care.

• Be aware that the use of templates may compromise accurate documentation, so make sure your documentation accurately describes the patient’s condition.

• Don’t let the computer become a communication barrier between doctor and patient.

• Read contracts carefully. Vendor contracts may attempt to shift medical liability risk from faulty software design onto the physician.

• Remember that all interactions with the EHR are time-tracked and discoverable.

• Know the source of the medication and clinical decision support information provided with the EHR.

• Follow HIPAA regulations related to protecting “individually identifiable health information.”

• When scanning or entering paper records into an EHR, comply with federal and state record retention laws before destroying old records.

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