Avoid Medical Error and Other Unintended Consequences of Electronic Health Records

Wed, Aug 19, 2015 --

Compliance, EMR/EHR

EHR, EMR, Health Records, electronic health records, unintended consequences

Unintended consequences is a vague euphemism for really bad things happening. According to a report prepared for the Agency for Healthcare Research and Quality, the unintended consequences of electronic health record (EHR) and electronic medical record (EMR) adoption includes a wide range of problems such as bad workflow changes, conflicts between paper and electronic systems, and the creation of an “illusion of communication.” All of these unintended consequences can lead to confusion, miscommunication, and medical error.

Avoid Unintended Consequences of EHRs With Multipronged Approach

Avoiding unintended consequences requires a multipronged approach, including active involvement of clinicians and staff in technology reassessment, continuous monitoring and resolution of problems that arise, interdisciplinary brainstorming to improve system quality and provide vendor feedback, careful review of skipped or rejected alerts from the EHR system, and creation of an environment that protects data entry staff from distractions while using the EHR system.

EHR Risk Not Limited to Privacy Breach

Many healthcare professionals and providers limit their view of EHR and EMR risk to HIPAA privacy and security violations through laptop theft, malicious hacking, and other vulnerabilities. But don’t forget the most important consequence of all, that of the potential for medical error caused by electronic medical record use.

EHRs Can Lead to Malpractice Suits

I attended the HIMSS annual conference and exhibition in April, and hands-down, the best presentation I saw there was by Keith L. Klein, MD, FACP, FASN, who reviewed EHR-driven medical errors that culminated in malpractice suits. Titled “Medical Legal Cases that Went South,” Klein’s discussion started with questions about the definition of the legal medical record, continued with a list of common pitfalls leading to litigation in the EMR, and finished with recommendations for change in the clinician workflow to avoid future litigation related to EMR errors.

As it turns out, according to AHIMA, no one-size-fits-all definition exists for the legal health record and designated record set. Rather, the healthcare organization must explicitly design these using medical staff guidance to ensure good patient care. The legal health record backs up patient care decisions, supports revenue sought from third-party payers, and documents as legal testimony services provided regarding the patient’s illness or injury and response to treatment.

One Case of an EMR’s Failure to Document Good Care

Klein’s presentation reviewed several recent malpractice cases where honorable physicians, all good, caring providers, were victimized by electronic medical record systems. In one case, a 65-year-old patient with renal failure underwent hip replacement, suffering complications during the hospitalization. After signing a consent form for the hip surgery, including the fact that he was at risk for possible acute kidney injury due to his preexisting renal condition, the patient had uneventful and successful surgery. However, after being scanned into the EMR, the consent form was lost. On the third postoperative day, the patient’s surgeon called for a renal consultation due to a rising creatinine approaching a danger level at 2.5. The renal medicine consultant saw the patient within 30 minutes of the call but didn’t write up the consultation note until later that day.

Ultimately, with good care given in the hospital, the patient recovered from the renal failure. However, he then sued the surgeon and the hospital, saying that he hadn’t been warned that he could suffer acute renal injury following hip replacement surgery. He also claimed negligence by the renal consultant.

In the printed EMR provided to the patient’s attorney and the court, the clinic notes were incorrectly dated, not backing up the consultant’s claim that he had seen the patient within 30 minutes of the call. Perhaps the worst documentation error from a legal standpoint was the use of copy and paste for subsequent progress notes; despite daily improvement in the patient’s condition, the copied and pasted progress notes showed identical information each day. From these records, the judge and jury inferred that no care had been rendered, and the plaintiff won a $1 million settlement.

Lessons Learned for EMR Documentation Practices

This case shares important lessons about good EHR documentation, said Dr. Klein. First, ensure that you obtain informed consents with an electronic signature to avoid losing scanned documents. Second, when providers use copy and paste to enter data in the EMR, they must make sure they edit the copied data to indicate what actually happened. Dr. Klein also recommends using what he calls the “triangle” system for EMR data entry by the provider, where patients and providers look at the EMR screen together. This encourages patients to correct any data entry errors they see the clinician make.

How About Your EMR and EHR Tips?

Do you have any tips for better ways to work with your EMR or EHR? Let us know in the comment box below. We love to hear from you!

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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