Regulation of Medicine
Electronic Health Records and Medical Malpractice Claims
June 3, 2020
Electronic Health Records (EHRs) are intended to make the lives of healthcare providers easier while improving the quality of patient care. In addition to automating and streamlining workflow processes, EHRs make it possible to instantly and securely share patient records with other authorized healthcare providers, giving you a broader, more inclusive view of your patient’s medical history. And, of course, EHRs help eliminate the potential for medical errors that result from poor penmanship.
As beneficial as EHRs are, however, they’re not without risks. In fact, evidence suggests that EHRs are increasingly a factor in medical malpractice complaints. Here are some tips to help you make the most of your EHR system and avoid potential liability.
Design your system to work the way you need it to.
If you use a system that’s non-intuitive, cumbersome or otherwise not quite right for your organization, you may be tempted to develop workarounds or other “cheats” that could compromise the accuracy of the records and your patients’ safety. Work with your system vendor and your staff to customize a solution that fits your needs: Include free text space for notes and clarifications. Pair consent forms with procedure templates. Add voice recognition or dictation features. Integrate labs and imaging providers. A few small changes can make a big difference, helping you increase efficiency while reducing frustration and user error.
Once you’ve developed your best system, allow ample time to transition to it. You’ll want to confirm that all patient records are transferred over completely and accurately, so your process should include a thorough review and comparison of the original files against the new records. Additionally, you’ll need to ensure that all staff is fully trained and comfortable with the new system. While it may require a bit more effort, doing things correctly from the start can save you from potential issues in the long-term.
Take steps to prevent user error.
EHRs are only as good as the people who maintain them. Instill good habits in yourself and your staff, and don’t take unnecessary shortcuts. If your system contains drop-down menus, always double-check your selections. Some menus include extensive options, many of which are quite similar to each other (for example, the same medication in all its various forms). Taking a few extra seconds to make sure you’ve chosen the right one will help you reduce mistakes. Also, while it may be tempting, avoid copying and pasting or auto-filling patient notes. Every patient and every examination are unique, and it’s important that your notes reflect that.
Customize alerts – and pay attention to them.
Alerts are an important part of EHR systems because they make you aware of potential problems. Maybe there’s a dangerous drug interaction you need to know about or the lab tests you ordered for a patient didn’t come back when expected. Or perhaps there’s a more immediate danger, like your patient developing risk for sepsis. EHR system alerts are there to remind you of or warn you about issues pertaining to your patient’s health, serving as a kind of backup program for human memory, so it’s important to pay attention to them.
Of course, when there are too many alerts, it’s easy to become desensitized and ignore them. One possible solution is to configure your EHR system so that you receive alerts only for critical elements of patient care. Some organizations have color-coded their alerts by urgency, while others have had success setting up the alerts by job role so that each person in the practice sees only those alerts that pertain to them. Talk to your EHR system vendor about what you need and don’t need. It may take some adjusting to find the right solution.
Enact appropriate security protocols.
EHRs contain confidential, protected patient information, so the system that houses them needs to be completely secure. Features like firewalls, encryption and restricted access are essential, as are good cybersecurity habits like locking computers when not actively in use and not sharing passwords. Train your staff on appropriate security measures, and conduct regular refresher courses. These sessions are also a good opportunity for your staff to make you aware of any issues with your EHR system that you may need to address.
While EHR systems can be a source of frustration, they’re part of the reality of healthcare today. Measures like these can help you maximize their potential, resulting in improved workflows, reduced liability exposures and enhanced patient care.
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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.