Ehrs and their role in medical malpractice cases

EHRs and Their Role in Medical Malpractice Cases EMRs have introduced liability risks and a medical record review could reveal issues in them that may lead to medical malpractice lawsuits.

Medical Record Review

In the face of a malpractice claim, the most important objective evidence that healthcare providers can offer are medical records. These documents when reviewed should offer strong and solid proof that the provider met accepted standards of medical practice at the time the care was rendered. If the medical documentation is weak or shoddy, it will without doubt impair litigation defense. When patient records are not well kept, it becomes difficult to conclude whether an untoward outcome resulted from the physician’s negligence or from factors beyond the provider’s control. While protecting patients, accurate and reliable healthcare records also offer providers a robust defense against medical malpractice claims.

Medical Records in Medical Litigation Whether paper or digital records, attorneys obtain copies of the relevant records when they are taking up a malpractice claim. To find out whether they have a legitimate case, they get the records reviewed by an expert medical review firm or an independent medical consultant. The reviewer will determine if the physician concerned provided appropriate care and whether he/she was negligent. Similarly, a doctor’s defense attorney also obtains and submits the relevant medical records for review and analysis. In either case, the strength of the documentation is the factor that determines whether the case can be taken forward. A dispassionate medical record review is what is required so that the attorney understands each element of the case, its strengths and weaknesses.

Serious Concerns with Electronic Medical Records It is in this context that electronic medical records raise some really serious concerns. As this author points out, EMRs have introduced liability risks and can lead to lawsuits where the physician finds himself/herself cast in an unfavorable light. The big issue with EMR is that they allow physicians to copy and paste previously entered information that results in perpetuating previous errors or leads to poor documentation of a changing clinical situation. In the 97 EMRrelated closed claims for the period 2007 to 2014 evaluated by The Doctors Company, 13% of the cases involved copy-paste as a contributing factor to medical malpractice. A medical doctor and professor of medicine, who spoke at the Healthcare Information Management Systems Society (HIMSS) Conference that was held this month, highlighted four such cases in which more than $7.5 million was granted to plaintiffs in various malpractice cases. This judgment resulted mainly from the lack of documentation in electronic medical records.

Providers and EMRs Both to Blame for Erratic Documentation The problem rests partly on providers and partly on EMRs. Providers may not enter healthcare details of patients in a timely manner or they may take shortcuts on entering the data. When www.mosmedicalrecordreview.com

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vital sign data moves from one hospital department to another it is often duplicated but remains part of one integral patient record. EMRs are complex and this creates issues with accuracy. A case the above mentioned doctor referred to involved a patient who unfortunately suffered permanent kidney damage as a result of the administration of an antibiotic to treat an infection that elevated his creatinine levels. This patient also had a uric kidney stone that prohibits the use of the antibiotic. However, because of the intricacy characteristic of EMR, none of the physicians who treated the patient noticed the kidney stone. A date associated with a previous intravenous drip was repeated again and again on all 3000 pages of the record, which made the EMR data unreliable. The repetitive data in the EMR could not be admitted as legal evidence.

EMRs themselves are also to blame. They are designed in such a way that they encourage erratic entries. Drop down menus for diagnoses, for instance, can enter data automatically if you hover the mouse over them too long. A misdirected mouse click could also record a misdiagnosis, which is a rather scary proposition. Another concern related with EMRs is that providers need to spend a lot of time navigating through various fields on the screen, and this consumes the valuable time they require to spend with the patients.

Addressing the Concerns Effectively However, we have to look at the positive side as well. EMRs are here to stay and if the technology is used properly, it should prove beneficial rather than detrimental. If implemented and utilized in the right manner, they should help save time and enhance accuracy while also ensuring care coordination as expected. EMRs differ from one vendor to another. It is vital that vendors reduce the complexity inherent in existing EMR systems and introduce the required safeguards. For the documentation to be accurate physicians have to be properly educated regarding the particular EMR system they are using and its intricacies, and take care to exercise more diligence when using it. Some measures providers could take to increase accuracy and prevent malpractice risk are: minimize scanning, be extra careful when using the cut and paste provision, be cautious when using built-in templates, minimize the use of the autocomplete feature and avoid note bloat.

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