Electronic Medical Records Errors and Legal Pitfalls
By PJ Papadakos, MD, FCCM, FAARC
Over the last decade, electronic medical
records (EMRs) have rapidly become the
adapted documentation standard in part
due to federal and insurance regulations.
Hospitals and practices have spent billions
of dollars on these systems and the hardware
needed to support them. Along with the
rapid access to data and automated systems
for documentation and billing have come
unforeseen problems. Caregivers and patients have noted that
there is now more interaction with the screen than with patients
and families. A term, “the i-patient,” has been coined to describe
this virtual patient a collection of data, labs and images that has
replaced the real patient as the focus of care. This, along with the
addition of “distracted doctoring,” and the explosion of personal
electronic devices, digital communication and social media
have further added to the loss of focus and the breakdown of
professionalism and mindfulness over the last decade.
Much of the growth of EMRs came as a result of a 2009 law that
created a “meaningful use” incentive program for implementation
of EMRs, dubbed the Health Information Technology for
Economic and Clinical Health Act. The massive economic
investment to digitalize medicine has been in some ways
beneficial in helping providers and health systems manage data
and information. This rapid introduction has also shown us many
pitfalls and introduced legal problems. EMRs were designed by IT
professionals instead of the physicians, nurses, pharmacists and
technicians who use them daily to care for patients. Patients also
provided no input on these systems to give patients easy access
to their care. These systems were developed first and foremost to
help the healthcare industry transition to a pay-for-performance
payment system, not to optimize workflow and communication at
the bedside. Because of the massive need for billing information
required by legislative groups and insurance companies, notes had
to be templated to contain “required” information. Check boxes
with dozens of options have led to information and medication
errors. Robust medication libraries have introduced click errors to
our medical terminology. There are also frequent failures of alarms
and alerts that overwhelm the provider and easily lead to alarm
fatigue. This, along with excess required information needed to
meet billing goalposts, have led to massive auto-populated notes
that overwhelm the provider. This endless need for data and not
caring where we are focused on a screen has led to a decrease in
human interaction. This has now been identified as the core issue
in healthcare providers having burnout.
The shift from human to digital documentation has also led
to a surprising legal issue: an actual increase in EMR created
malpractice issues. EMR related medical malpractice claims have
risen over the past decade, according to the Electronic Health
Record Closed Claim Study generated by the Doctors Company,
the nation’s largest physician owned medical malpractice insurer.
User errors, including data entry, copy and paste mistakes,
medication choice errors along with click errors on dosages, and
alarm fatigue issues have shown up in 58 percent of claims in the
study, compared with system factors contributing to 50 percent
of claims. This is contrary to what health providers were led to
believe. This study has become a wake-up call to get the word out
that errors do occur with EMRs and affect patient safety.
The other concerning issue after these data entry and
documentation issues are the potential negative impact on the
provider-patient relationship. Prior to EMRs, the written narrative
would give the reader an individualized feel for each patient. The
one-to-one interaction created a bond between the provider and
the patient. Direct eye-to-eye contact and the laying of hands
were key in placing the patient at ease to share information with
their provider. The EMR screen has led to a physical barrier,
which many patients complain has led loss of eye contact. The
provider has their back turned and is entering information onto
the all-encompassing screen. The asking of templated questions
having nothing to do with the complaint at hand, and the
shotgun approach to tests needed to meet guidelines have eroded
the patient visit. The constant beeps and alerts both from the
EMR and the providers devices have generated an environment
of interruptions that have also added to the breakdown in the
concentration needed to get to a diagnosis. This digital medicine
has now become a standard and can only lead to further problems
in the practice of medicine, loss of trust and increased costs.
Hospitals, professional schools and providers need to move from
an IT-dominated world back to a humanistic world. The two to
three hour courses on how to use the EMR and collect data need
to evolve into robust courses that teach electronic etiquette and
technology integration in healthcare. Providers need to understand
the EMR pitfalls and partner with patients and designers to
improve the workflow to again center on the patient and not a
collection of data. Error-generating platforms need to be corrected
to make them human friendly with built-in checks. Alarms and
alerts need to be customized to provide proper goalposts. Facilities
and providers need to understand that technology is not a cure
all, but is only one part of healthcare, a tool that its use most be
taught like any component of the practice of medicine.
PJ Papadakos, MD, FCCM, FAARC, is a practicing intensivist who has
become an expert on the integration of technology into healthcare. He
and Dr. Stephen Bertman edited the new text “Distracted Doctoring:
Returning to Patient Centered Care in the Digital Age,” an imprint of
Springer Publishing.
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