Electronic health records – factors contributing to medical malpractice risk

Electronic Health Records – Factors Contributing to Medical Malpractice Risk EHRs facilitate important processes such as medical records review, and medical coding but are associated with certain risks.

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Electronic health records or EHRs are becoming part of all physician practices though physicians face many challenges when implementing the same. This electronic system is expected to improve medical documentation and facilitate important processes such as medical records review, and medical coding and billing among others. It is also expected to improve care and population health, while lowering healthcare costs per capita. Amidst the many benefits, EHRs can also create medical liability risk. A review of EHR related medical malpractice claims by a national medical liability insurer found that 42% of malpractice claims stemmed from system errors and 64% from user factors.

Let us consider the factors that can contribute to EHR liability. 

Issues with e-prescribing: Electronic prescription programs that have replaced prescription pads transmit directly to pharmacies. However, all programs cannot validate the drug dosages, check drug interactions or include prescriptions from other physicians. Lack of specialty-specific functionalities in many EHRs can pose risks to patients and lead to malpractice. Another problem is that most e-prescribing programs don’t store information from other providers who may be using other eprescription programs, which can compromise patient safety. Physicians must verify that the EHR uses drugs specific to each specialty, calculates the correct dosages and also alerts the provider in case of any contraindications or dosing errors.

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Problems with interoperability: Limited functionalities and multiple EHR systems and platforms create interoperability problems. Issues with the ability to exchange and use information makes it difficult for physicians to gain immediate access to details such as ER visits, hospital admissions, lab results, and acute care provided outside the hospital among others. EHRs that are incomplete can contribute to grave errors in the medical management of the patient, harm the patient and expose physicians to medical malpractice risk. In the present scenario, physicians should ask patients about any short-term care received at other locations and also get treatment summaries from other providers directed to the present hospital or medical home.

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The copy-paste issue: Copying and pasting clinical information from earlier medical encounters may lead to over-documentation of the actual findings. This risk is even more when the document cites information that has changed or items that were not examined in the following visits. These are serious errors that can totally damage the

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integrity of the record in case of a liability action and also throw doubt on other parts of the medical chart. 

Failure to review incoming patient reports before entering into EHRs: Busy physician practices and hospitals have huge volume electronic patient reports coming in every day. If these are not examined by the concerned provider before incorporating it into the EHR, it can pose a grave malpractice risk. Medical errors can be prevented by having in place a robust system to examine and authenticate incoming patient reports to EHRs.

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Lack of security features: EHR should have strong security features to counter threats such as lost thumb drives, stolen laptops and cyberattacks. It is important to ensure that all devices containing patient data are password protected, encrypted and also meet all mandatory requirements of HIPAA. Physicians should have a clear idea about their coverage for data breaches and other HIPAA violations.

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Non-compliance with applicable state and federal medical record retention laws: When transitioning from paper to electronic records, physicians must ensure compliance with all relevant record retention laws before destroying written records.

It is also very important to scrutinize all EHR vendor and service contracts and obtain legal counsel regarding the same. The risk is that EHR contracts may have wording that shifts the liability stemming from faulty software design or inappropriate clinical decision support to the EHR user. Or else, there may be restraining clauses that prevent buyers from publicizing information about problems encountered. Physicians using EHR should know where the PHI (protected health information) is stored and also the risk involved in losing such information. In addition, they should also implement EHR continuity plans in the events of an EHR vendor failing, a practice dissolving, or a solo practitioner retiring.

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The issue of upcoding: EHRs may have features that automatically calculate CPT codes based on the services documented in them. Sometimes services could be coded at a higher level than required. Improper coding can lead to overpayments and allegations of fraud and abuse.

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There is no doubt that electronic health records have many advantages, but there are risks such as the above involved. Physicians using these systems must ensure that their EHR is practical and efficient and be aware of the malpractice issues. This will help them make the best use of the EHR, while also providing superior quality care to their patients.

www.mosmedicalrecordreview.com

(800) 670 2809