Electronic Medical Records Increase Potential Liability for Physicians

Guest post by Keith L. Klein, MD, FACP, FASN.

The use of electronic medical records (EMRs) is increasing liability risks for physicians. We have not yet seen the full impact of EMRs, because cases take three to four years to be filed from the time of the adverse event. However, we are beginning to see data that show EMRs are a contributing factor in malpractice suits.

In a study by The Doctors Company of 97 EMR-related closed claims from 2007 to 2014, user factors contributed to 64 percent of claims, while system factors contributed to the remaining 42 percent. EMRs can result in a weak defense by casting the user—the physician—in an unfavorable light.

In a recent presentation I gave at HIMSS, I outlined malpractice cases that involved EMRs that resulted in cumulative awards of more than $30 million and reviewed areas where EMRs present the greatest risks.

Risk 1: Copy-and-Paste

Copying and pasting previously entered information can perpetuate any prior mistakes or fail to document a changing clinical situation. In The Doctors Company study, 13 percent of cases involved pre-populating/copy-and-paste as a contributing factor. While it may be OK to use the copy-and-paste function to save time, whatever is pasted must also be edited to reflect the current situation. Similar to copy-and-paste is the practice of using templates. Some of the biggest pitfalls in these two functions are lack of individualized information on the patient, gender confusion, lengthy notes for each encounter that look like they have been enhanced by the computer, lots of blanks, repeated typos and other errors, and use of similar phrases sequentially.

Risk 2: Informed Consent

Physicians must take care to capture the electronic signature of the patient when loading an informed consent into the EMR. Make certain the signature is legible. Also check to be sure the scanned document is in the record and that the informed consent is documented in the notes.

The following is from a case that involved problems with informed consent in the EMR:

Risk 3: Shortcuts, Check boxes, Checklists and Auto-complete Functions

Other danger areas are the use of shortcuts, check boxes, checklists, and auto-complete functions. Check boxes, particularly those that pre-populate, can be a physician’s nightmare. Physicians should use shortcuts and auto-complete functions sparingly. It is better to include individualized information about the patient than to resort to auto-complete.

Risk 4: Writing Notes

It is the accepted practice, especially on teaching rounds, to see all patients and then write notes at the end of the day. The EMR automatically dates and time-stamps the physician’s note at the time the note was created. This gives a misleading impression of when the patient was actually seen, and in a rapidly changing clinical situation, the note may not accurately reflect the patient’s clinical condition at the time the physician actually saw him. Therefore, it’s important to state in the note the specific date and time the patient was seen and examined.

The fundamental mantra when writing a note in an EMR is to show you put thought into the record. Free-text entry of three or four sentences conveys far more than several pages of template-driven notes and accurately reflects your visit with the patient. Vast amounts of information loaded into notes are not the same as knowledge.

The following is a case that involved problems with note-taking:

And later in the trial:

Risk 5: Alert Fatigue

Physicians receive far too many alerts in any one day, leading to alert fatigue and subsequent mistakes when having to concentrate on entering data into an EMR.

All these common EMR issues cast doubt on the integrity of the doctor and the medical record and may lead to adverse decisions in court, as well as increasing the chances of an unfavorable audit by insurance companies or CMS.

Write a Comment

Your email address will not be published. Required fields are marked *