We live in the information age. You can purchase everything from groceries to automobiles online, and nearly everyone banks online. The internet is also a great place to back up records, which brings us to the EHR or Electronic Health Record. In his 2004 State of the Union address, former President George W. Bush introduced a plan to roll out EHRs across the country, stating, “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”
An Electronic Health Record is an electronic version of a patients medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates access to information and has the potential to streamline the clinician’s workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.
But EHR’s are not foolproof and can and have resulted in medical malpractice claims. According to a recent report from Becker’s Healthcare, EHR-related medical malpractice claims have tripled since 2010. The types of EHR claims in the referenced study most often included systems technology, design, or user-related issues, for example doctors allegedly copied and pasted old, outdated patient progress notes from previous medical appointments into the EHR, rather than entering new notes at each patient appointment.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.
The system and user errors should come as no surprise to health information professionals. The system factors reflect problems associated with electronic records that include—among other things—access, integration, and data security. The same might be said for the user factors. It is up to the providers to enter new, accurate progress notes in the EHR at every patient encounter. 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 and should consistently take action to identify, reduce and correct medical errors. Taking steps to report and reduce patient risks and harmful outcomes protects patients and providers, and bolsters improvement to the quality of medical care.