Author: Peter J. Papadakos, MD, FCCM, FAARC
Practitioners and health facilities have invested billions of dollars to meet the edicts of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was signed into law in February 2009. Its mandates encouraging providers to adopt electronic health records (EHRs) have led to widespread adaptation in provider offices (currently at 80%) and hospitals (currently at 90%).
EHRs were supposed to advance both the practice of good medicine and patient safety. Due to its rapid adaptation, and the fact that it was a government requirement, there were many unanticipated negative consequences. The basic problem of the HITECH Act was that its core principle was not the practice of good medicine, but rather it was for medicine to transition from a volume-based (fee-for-service) payment system to an outcome-based (pay-for-performance) payment system, which had nothing to do with optimizing productivity, workflow and communication within medicine but rather had to do with reimbursement. Many clinicians were shocked to find that in this digital era, productivity went down, the ability to relate to patients was compromised, and the ability to navigate the patient record became more difficult.
Data from a 2011 report from the National Academies of Sciences, Engineering, and Medicine, titled “Health IT and Patient Safety: Building Safer Systems for Better Care,” concluded that the information needed to analyze and assess the safety and use of health information technology (HIT) were not available, and our understanding of the risks and benefits was anecdotal. The government recommended the creation of a new agency that would systematically and uniformly collect data to investigate harm and safety events related to HIT. Thus, in 2015, the Office of the National Coordinator for Health Information Technology developed a plan to create a HIT safety center to minimize EHR-related patient safety risks through the collection and analysis of event data reported by users.
Unfortunately, if implemented, the HIT safety center would not include an online mechanism for EHR users to report EHR-related adverse events in “real time” as they occur, which I believe makes the process useless. The core problem is this: When new technologies are rapidly adopted, there are many unanticipated consequences. EHR systems are no exception.
This was magnified by the fact that health professionals offered minimal insight into these EHR systems. Why would having health care experts’ input in designing a health care record system make any sense to IT and government officials? Thus, health professionals have had to deal with flawed programs that led to errors and may also have inherent pitfalls that lead to malpractice suits.
This idea is now backed by an EHR claim study from The Doctors Company, the nation’s largest physician-owned malpractice insurer. In the study, it was found that 58% of 66 EHR-related malpractice claims between July 2014 and December 2016 were due to user error, such as faulty copying and pasting. Half of these claims also showed technical issues or glitches in the software. It is important to understand that a single mistakenly checked box on an electronic form can lead to a patient being overdosed, underdosed, and having a disease added or not added to his or her history, thus leading to major problems—and even death. These symptoms have also led to cookie-cutter medical care and neglect of patient individuality, and have helped curb the doctor–patient relationship in a manner that I describe as “dehumanizing medicine,” which further adds to increased litigation.
So, how can the provider deal with this flawed system? The answer is education. Medical providers at all levels need to gain exposure to digital training along with their traditional education in pharmacology, physiology and physical diagnosis. Human-to-technology interfacing should have a major role in training providers to recognize, evaluate and correct faults in computer records, guarding against errors and increasing patient safety, which could prevent legal misadventures. Here are some key points that illustrate recording errors and poor practices.
Insufficient Area for Documentation (Drop-Down Menu)
Many records currently in use have extensive drop-down menus that are there to “help” write your note. The classic admission note has been lost. A once detailed narrative written by the provider not only supplied a list of complaints and symptoms but also gave you a sense of the patient: his/her wants and needs and how the disease was affecting the patient. Taking time to free write a note like this will also cause you to focus on lab results, images and other data that are now autopopulated into massive disconnected notes. I will illustrate how autopopulation and lack of insight by the provider can lead to a poor note and thus a legal issue. Many autopopulating notes draw from a problem list library. If the information is not entered in the proper place, note after note may have a statement such as “no medical history on file.” In this illustrative deposition, a 59-year-old with a complex medical history, including liver transplant, is admitted to the hospital with pneumonia. Yet, note after note says there is “no medical history on file.” The attorney then asks the provider over and over again, “Doctor, are all of your records this poor? Do you really know nothing about your patient?” It is thus incumbent that all providers document a complete medical history by asking the patient and then recording that history in their note as well as the database.
Copy and Paste
One of the most common problems in EHR notes is copying and pasting previous notes. It is not to say that this is always a problem when copying key lengthy documentation for single use in a signout or consult note. If, however, the narrative never changes from day to day, this can become a major source of legal problems. A patient is extubated on day 5 of an ICU admission, but notes from day 6 through 8 continue to show the patient is intubated and on the same ventilator settings, despite clear documentation from the respiratory therapist and the nurse that the patient is on a face mask and participating with pulmonary toileting. Defense experts can question whether the physician had done a complete assessment because his/her progress note from the most recent visit appeared to be identical to the progress notes for the three previous days, including the same information along with identical spelling errors, suggesting that no original evaluation had been generated.
EHRs contain robust pharmacologic libraries with multiple dosages. This can greatly improve patient care but can also lead to grievous errors. As an example, one of the malpractice claims included a very telling case of how simplification can lead to a dangerous error. An elderly woman saw an otolaryngologist for an ear/nose problem. The physician intended to order Flonase (fluticasone, GlaxoSmithKline), a common nasal spray. The patient filled the prescription and took it as directed. Ten days later, she presented to an ER with dizziness. Two weeks later, the pharmacy sent a refill to the physician at his request. The prescription was for Flomax (tamsulosin, Boehringer Ingelheim), a drug used in men for prostate issues that has a common side effect of hypotension. It seems that the EHR system was designed to aid the physician. When ordering, the physician typed “FLO” in the medication order screen. The EHR automatched Flomax, and the physician, without thinking, clicked on it. There was no order confirmation system in place and no automated process to alert the physician, which would alert the order writer or the pharmacy that this was a gender-specific drug. It is sad that there are more checks when ordering a shirt online than in EHRs that deal with medications.
Another issue in these pharmacy EHRs is that the drop-down menus for dosages can generate either an under dose or an overdose. One such claim illustrates this so-called click error. A patient is evaluated by her physician for a pain issue. The physician orders 15 mg of morphine sulfate every eight hours. In this EHR, the drop-down menu offered 15 mg of morphine followed by 200 mg of morphine. The physician inadvertently selected 200 mg and did not recheck before completing the order. The patient filled the prescription, took one dose of 200 mg along with alprazolam (Xanax, Pfizer), and developed slurred speech requiring emergency care. Again using online shopping as an example, an individual is ordering five pairs of plaid shorts, but the keystroke enters 50 at the end of the order. The online shopping system has an order confirmation page that needs to be reviewed prior to submission; not so with most EHRs.
Improper Template and Documentation Issues
Many templates are used to treat common complaints, and vast libraries are built into EHRs to support billing. Here is an example as reported in the claims study: A patient is evaluated by a hand surgeon for a left ring finger injury. No fracture is noted. The surgeon mistakenly clicks right. Thus, his documentation shows an injury to the right finger throughout his EHR note. It also contained default extraneous and inaccurate information that was automated, including mentioning a fracture and an incorrect medication the patient did not receive. It did not contain follow-up instructions, and the surgeon never finalized or signed the note. Six months later, the patient saw a different surgeon who noted the left ring finger had no flexor tendon function. MRI showed a complete tear. Subsequently, the first surgeon reviewed his EHR note from the initial visit and “corrected” the inaccuracies. He removed mention of the fracture, corrected the medications, and stated the patient had been told to follow up in 10 days. He then electronically signed and finalized the note. The EHR, of course, documented the original keystrokes and the changes made weeks later, thus converting an error to a level of improper legal behavior documenting fraud. A practitioner should never correct a note in such a way when he/she can simply write a clean addition, which is properly timed and dated.
In a busy academic setting, an attending physician may be supervising a team of residents and midlevels in the care of patients. The staff directs notes and consults into the attending’s inbox. The attending by his electronic signature is certifying that he had active input, not only in supervision but also evaluated the patient and had input on the care of the patient. The cosign system may lead an attending to bulk sign a collection of notes in an office or at an off-site location. In a hearing, we can see the implication of an attorney pointing out that the doctor had signed 200 notes in 15 minutes two weeks after the evaluation from his vacation home. The follow-up question implies that the doctor never really evaluated any of the patients and never added anything other than his signature. This realization can have devastating implications.
Ideally, documentation would take place during rounds or shortly thereafter, and add customized data and input. An example would be: I evaluated the patient with Steve this morning. I noted increasing abdominal tenderness and an elevated white blood cell count. We decided to send the patient for a CT scan and to get a surgical consult later today. If signing in a location that is outside the unit, it is important to remember that IP addresses are imprinted into the note. Adding a statement such as, I evaluated the patient with my team earlier today, and I am completing this note in the quiet of my office. Of note was a falling HCT [hematocrit] and some dark-colored stool. I suggested a GI consult and will await their input. Such statements support the care of the team and provide your direct input and concern and contain an honest statement of the workflow in a busy academic practice.
EHR Conversion (Incorrect Information in the EHR)
This claim illustrates the point of how important it is that both you and your team are trained to review the information entered and transmitted in the EHR. Many errors occur in both entry and conversion from written records. A patient with Tourette syndrome was treated with 0.5 mg of haloperidol (Haldol, Janssen) and documented in the old record. The patient called the office requesting a refill. The nurse entered “Haldol 5.0 mg” in the new EHR for an electronic prescription. This refill request showed up as a task for the physician to complete. The EHR was new, and it was the first prescription for this patient. The intended dose (0.5 mg) was therapeutic. The patient took the new dose (5.0 mg) for six months before anyone discovered the error. The patient had several side effects, including cough, weight loss and not feeling well. All of this could have been prevented by double-checking the old data, and if the pharmacy had contacted both the patient and the office regarding the manyfold change in dosage on the prescription—something you would expect in this digital world of data exchange.
These claims not only illustrate the complex nature of EHRs but also show how as humans, we never developed so-called “human to technology interfacing” or electronic etiquette. We must learn how to interact with the patient and the EHR in such a way as to provide humanistic care that is both accurate and safe. In establishing how best to treat a patient and have the EHR reflect that, I emphasize that the burden does not lie solely on the health care provider. Rather, patients must also play a key role in being proactive, reviewing their records and voicing their changes.
I believe technology has become the third party in the room with the patient and provider, assisting both of them equally. Patients can look and see whether their histories and medications noted in the EHR are correct. They should have the ability to communicate with their health care providers if there are errors. The pharmacy and consultants should also be integrated into the systems so there can be checks on the system. We as health care providers should work with technology developers to improve EHRs so they reach their full potential and reconnect the patient and providers to provide the highest level of health care in the safest manner.
Peter J. Papadakos, MD, FCCM, FAARC, an anesthesiologist at University of Rochester Medical Center, studies and writes on the effect of technology in health care. He serves on the advisory board of Anesthesiology News. He and Stephen Bertman, PhD, have edited a new book titled “Distracted Doctoring, Returning to Patient-Centered Care in the Digital Age,” available from Springer Publishing (2017).