Use of Templates: Jeffrey Kagan, MD, a Newington, Ct.-based internist, has experience reviewing malpractice cases for attorneys. One trend he has seen related to EHR-induced malpractice suits comes from template use. "Templates are supposed to help us do something more comprehensive, but often our templates have a lot of old information that carries forward. You can modify them, if you remember to. If you don't, whatever was there from before appears again, whether it's appropriate or not," he says, adding that the use of templates leads to laziness among physicians, who aren't properly documenting the patient's visit.
In order to avoid falling into this trap, Kagan advises physicians to proofread and modify templates if they are going to be used. He also says to document in the EHR whenever possible to cover yourself. "I tell every patient, 'Call if you aren't feeling better.' If the patient says I never told him that, I have it written next to my signature in every note," he says.
Alert Fatigue: The e-prescribing module in an EHR is a potential landmine for malpractice, says Troxel. He notes that alerts indicating when there is a problem with medication dosage or drug-drug interaction will pop up as practitioners are inputting data into the EHR. "They are very annoying because there are so many of them. I'm told by [EHR users] they arise whether you are prescribing aspirin or a complex antibiotic," he says. "As a result, doctors get annoyed and develop alert fatigue, and they just turn the alerts off."
Troxel says while this is understandable, turning off the alerts could mean a potential significant problem could go undetected. Lugtu says that while medication allegations come up most frequently in EHR-related malpractice suits, they don't typically have a high severity outcome. Either way, experts say physicians should not just blindly override these prompts.
Clinical Decision Support Alerts: Another prompt that goes ignored, often to the determinant of the patient and the doctor, are clinical decision support (CDS) alerts. These are clinically relevant educational materials that come up as the practitioner is documenting in the EHR. Like with medication alerts, Troxel says practitioners should ignore these at their own peril. If anything, he says, physicians should document the reason why they overrode the CDS alert.
Missing Information: While most of the errors are primarily user-related, there are problems, according to Lugtu, with poor technology design too. She says an "interface breakdown" can mean providers will miss necessary information, such as a test result, to make a proper diagnosis. These often occur immediately after implementation of a new system, she says.
The idea of physicians missing a vital piece of information in the EHR can be either a user or a technical error, Lugtu notes. "When a physician doesn't see a test result, it can be [a poorly designed interface], it could be [the information] wasn't routed correctly, whether the physician wasn't notified of the result being there, or the physician clicks it as seen without actually reviewing it," she says.
These are just a few of the potential areas where the EHR can lead to a malpractice suit. Lugtu advises physicians to read educational resources on healthIT.gov and AHRQ, as well as the nonprofit patient safety organization, ECRI Institute, and elsewhere to keep abreast of best health IT safety practices. She also says it's important to embrace the technology, not hide from it.
"While we're finding the EHRs are involved malpractice suits, we believe even more so, that they are beneficial in preventing many types of [false] allegations. We're not saying practices should put the EHR down, we want to boost it up while making sure it's not an issue," she says.