Electronic Medical Records (EMRs), according to the general medical community, serve as an unnecessary obstacle to practicing medicine. As a result, many physicians are resistant or slow to adopt the utilization of EMRs. Case law establishes physicians can be held liable for harm that could have been averted had they more carefully studied the records, which are most commonly electronic. Furthermore, HIPPA identifies the healthcare provider as the covered entity responsible for maintaining the integrity of a medical record. Should a medical negligence/malpractice suit arise, EMR vendors can defer blame because they do not practice medicine. Therefore, physician adoption and proper utilization of EMRs is paramount in the reduction of medical negligence/malpractice claims. Below are six common causes of medical negligence healthcare providers should avoid in relation to the use, or lack thereof, of Electronic Medical Records:
1. Copying and pasting:
In the case of Short v. United States, an intern at the Veterans Administration Hospital in White River Junction, Vermont, was held responsible for the damages suffered by the plaintiff, whose prostate cancer went undiagnosed as the intern failed to review the patient’s past visit notes. A discrepancy between records was created when important patient data was lost as a result of copying and pasting from one EMR to another.
2. Ignoring Clinical Decision Support (CDS)
Physicians are often annoyed by Clinical Decision Support (CDS), as they feel it instructs them how to practice medicine. For example, patient records might prompt drug and allergy alerts. As a result, doctors and healthcare facilities create system overrides, quickly click past alerts, or do not properly install CDS in the first place. It is important to note that the information provided by CDS alerts can prevent harm or injury to patients, even if it is irritating to healthcare professionals.
3. EMR customization
Doctors are notorious for writing notes on electronic patient records rather than checking off the appropriate boxes provided by the EMR system. For example, a physician might write “allergic to aspirin” in an additional note dialogue box, rather than clicking the “aspirin” box under the “patient allergy” section of an EMR. Doctors should not bypass EMR design in this manner, as often times, an EMR system is not smart enough to create a CDS alert based on general notes. If healthcare professionals use EMR systems as they are intended, CDS alerts will be prompted that can potentially prevent patient injury or harm.
4. Not considering proper use of EMR as Standard of Care
The implementation of EMRs has, in a sense, changed the Standard of Care for healthcare professionals. Because the proper documentation and utilization of EMRs can serve as a tool to prevent potential patient harm, there is no reason doctors should not use it in their practice. It is now a de facto Standard of Care.
5. Input errors
The carelessness of physicians and other healthcare professionals can lead to error when transferring patient records from paper charts to an EMR system. Common errors include autofill errors, neglecting to provide a signature, random deletions, and printing problems. According to a recent study of 1,891 VA patient records, at least 84% contained one or more errors. On average, there were 7.8 errors per patient record.
6. Being irresponsible with passwords
Sharing passwords is common among healthcare professionals, particularly in smaller practices, which can lead to unorganized chart entries. Healthcare professionals are also commonly guilty of never changing their passwords. Both of these habits make EMR systems and patient information susceptible to hackers, especially if employees use computers with EMRs for personal use or downloads.