There is a disconnect between what the doctor may have ordered and what the EHR read or translated.
In my capacity as a healthcare consultant and auditor, I review patient records from all over the country – actually, the world, with the ever-growing popularity of offshore companies now performing coding and billing for U.S.-based physicians’ practices. In these reviews, I have also noticed a trend reflecting a disconnect between what the physician may have ordered for a treatment option for a patient, and what the digital system, the electronic health record (EHR) software, actually read or translated. There is also a great capacity for error, meaning that one sleight of hand by a provider using a dropdown menu can cause a patient serious injury.
One medical malpractice insurer, The Doctors Company LLC, gave a scary example recently, wherein a patient was treated with trigger point injections of opioids for pain management. The physician intended to order morphine sulphate, 15 mg, to be administered every eight hours. The EHR dropdown menu offered 15 mg and 200 mg. The physician mistakenly selected 200 mg. The patient filled the prescription and took one dose with Xanax, then developed slurred speech and was taken to the emergency department (ED), resulting in overnight hospitalization and a malpractice claim against the physician for emotional trauma and the costs of the ED and hospital stay.
This type of EHR-related medical malpractice suit is becoming more common. For the past eight years, claims in which the use of EHRs contributed to patient injury have reportedly been on the rise.
Where Do EHR-Related Risks Come From?
EHR-related claims filed from 2010 to 2018, wherein errors and/or potential risks were found, based on a survey by this medical malpractice provider, were caused by either system technology and design issues, or by user-related issues.
System Technology and Design Issues:
Electronic systems/technology failure
Lack of or failure of an EHR alert or alarm
Failure of electronic routing of data
Insufficient scope/area for documentation in EHR
Lack of integration/incompatible systems – interoperability issues
Failure to ensure information security
Case Examples: System Technology and Design Issues
Case No. 1: Electronic Systems/Technology Failure
- Presentation: An elderly female patient presented to an otolaryngologist for sinus complaints. The physician intended to order Flonase nasal spray. The patient took the medication as directed. Two weeks later, the patient went to the ED for dizziness.
Outcome: The ED physician discovered that the patient was taking Flomax: a medication for an enlarged prostate, one side effect of which is hypotension. The original ordering physician had entered “FLO” in the medication order screen, and the EHR automatically selected Flomax. Not noticing the error, the physician selected it. There was no EHR drug alert for gender.
Case No. 2: Fragmented Record
- Presentation: A 55-year-old male patient presented to the ED with back pain. He was diagnosed with severe lumbar stenosis. Following surgery, nurses noted neurological changes. They documented the changes and called the physician, but no action was taken.
- Outcome: Due to a fragmented record (both paper and EHR), information was not communicated to the correct physician. The delay in contacting the correct physician resulted in a delay of return to surgery and partial paralysis.
These scenarios clearly reflect serious concerns about interoperability and other external systems interfacing with physician practice EHR systems.
When it comes to “user-related” issues, this is where my auditing insight has shown me where cloned noting, the cut-and-paste method of bringing patient information forward that has not been updated, and simply lack of communication in the EHR, with providers that are treating the same patient, can cause not only unbelievable risks for physicians but potentially fatal outcomes for patients. Here are a few examples of user-related issues in the EHR:
Case Examples: User-Related Issues
Case No. 1: Copying and Pasting
- Presentation: A physical medicine physician followed a patient with extreme weakness due to cervical vascular malformation. Nurses and a physical therapist noted neurological changes, but the physician’s note indicated no changes. The physical therapist contacted the attending physician to discuss neurological changes, including increased weakness. The physical therapist asked the physician to order a neurological consult due to the patient’s deteriorating condition.
- Outcome: The physician ordered the consult, but did not explain why his documentation did not address the patient’s changing condition. The patient was taken to surgery and now has incomplete quadriplegia. The physician was criticized for copying and pasting the same note for four days and delaying the intervention.
- Case No. 2: Copying and Pasting
- Presentation: A 38-year-old obese patient presented for medical clearance. His test results were normal. Three months later, the patient presented with shortness of breath and dizziness. His blood pressure was 112/90 and pulse was 106. No tests were ordered.
- Outcome: Five days later, the patient expired from a pulmonary embolism. Experts questioned whether the physician had conducted a complete assessment. The progress note was identical to the previous note from three months earlier, including old vital signs and spelling errors.
Based on a recent Forbes Magazine piece, an investigative report conducted by Kaiser Health News, dove into the push from the Obama administration a decade earlier to digitize medical health records in order to “ lessen the paper-pushing, lower administrative costs, and allow physicians the means to do their jobs easier.” Now, here we are a decade later, and the opposite has proven true. EHRs have led to unnecessary deaths, contributed to a steep drop in doctor-patient interaction, and yielded little to no cost savings to the physician or the patient.
The EHR push started with the 2009 American Recovery and Reinvestment Act, which approved billions in spending to encourage the healthcare industry to embrace the new technology. Doctors and hospitals that failed to adopt a government-approved digital system by the end of 2014 faced cuts in their Medicare reimbursement, so providers rushed to implement EHRs.
But these EHRs ended up being seriously flawed, and arguably dangerous for patients. They were not vetted, beta-tested, or under any regulatory oversight before physicians were pressured to find a system.
For one, patient records routinely have errors. When I audit from remote access into an electronic health record, I’ve had a few cases wherein the patient profile displayed a doctor’s note for a different patient. Other issues abound. Systems are supposed to flag potentially dangerous drug orders, but often fail to do so. Records frequently do not list the correct start and stop dates for prescriptions. Also, transmitting data between systems continues to be a huge challenge.
These errors alone are enough to prove that the EHR mandate did far more harm than good. But they’re not the only negative consequences electronic health records have created for patients and doctors. The physicians are not spending more time with patients, which was promised; they are spending more time dealing with the paperwork associated with completing their work in the EHR.
So, how do we address this problem of risk and errors in the EHR? As a foundation, practices should have processes in place to monitor EHR issues and prioritize the need for EHR redesign based on risk. Identifying common EHR-related pitfalls and establishing risk mitigation strategies to minimize the chance of patient harm are important results of closed claims studies.
Listen to Terry Fletcher report this story live today during Talk Ten Tuesday, 10-10:30 a.m. EST.