Incorrect use of EHRs can prove costly to healthcare providers, and so this is something providers have to be very wary about. Medical records are distinctive pieces of evidence in medical malpractice lawsuits and can make or break the physician’s career and prospects. The sad side of EHR use is that often the mistakes a physician makes may be unintentional but would still have to pay a price because of the serious nature of the injury caused to the patient. Let us consider the actual risks involved in using EHRs.
- Failing to enter comments in relevant fields when required
- Making retroactive changes in the health records thinking that it will not be discovered
- Trying to manipulate contents and time stamps
- Auto populating feature of EHR that may automatically fill in information that is incorrect.
- EHR templates have drop down menus that make data entry easy. Since these menus are integrated with other automated features, an entry error may be perpetuated to other parts in the EHR. If it is overlooked, a new possibility of error is created and repeated.
- E-prescribing drug information and CDS databases are provided in EHRs (as required by Meaningful Use). Providers should know the source of the drug and CDS information in their EHRs, because it may be in conflict with the practice guidelines or clinical standards for their specialty and with the information in the FDA-approved drug labels/alerts.
- CDS provides alerts, reminders and warnings for medication, preventive care and chronic disease management. Physicians will have to justify any departures from these guidelines if an untoward event occurs. It is important to document why a prompt or alert was overruled.
- E-prescribing is now being increasingly adopted, but it has its cons as well. For instance, consider a doctor X who changes a medication he has given one of his patients and receives an alert from the e-prescribing program that the drug may conflict with another drug the patient is taking (prescribed by Dr. Y, who is also treating the same patient). Dr. X will have to contact Dr. Y to decide which drug can be stopped or changed. If this is not done and patient injury results from a drug interaction, Dr. X may be sued for malpractice.
- Copy-pasting information or “cloning” poses a real threat with EHRs. Templates compromise the quality of notes and documentation; in the absence of narrative documentation of day-to-day events and the patient’s progress, the treatment course may not be very clear. Lack of information or loss of information can prove costly.
- There is always the risk of vendors trying to shift liability due to faulty software design or CDS data on to the physician. It is crucial to read all vendor contracts very carefully because malpractice policies may exclude coverage for product liability and indemnification of third parties.
In a malpractice case, lawyers may request printed copies of the EHR as well as copies in native format (that shows how the data was used) for medical record review purpose. They will want to see whether the provider had followed CDS alerts and prompts or overridden them. A proper medical case summary will be prepared highlighting important aspects of the case. Physician interactions with their EHR will be carefully reviewed to determine malpractice.