EMRs: A 'plaintiff's dream'? reduce your risks
EMRs: A 'plaintiff's dream'? reduce your risks
When an ED physician was sued for allegedly missing signs and symptoms of a subarachnoid hemorrhage, the emergency medical record (EMR) documentation that was brought into evidence didn't help matters.
The nursing notes stated that the patient complained of severe headache and vomiting, while the physician's notes described sinus congestion and nausea. The physician's review of systems, moreover, which were documented as a "macro" that popped up when the physician checked "all other systems reviewed and negative," stated that the patient had neither headache nor vomiting.
"The chart showed multiple contradictions. There was no easy way to reconcile these differences," says William Sullivan, DO, JD, FACEP, director of emergency services at St. Mary's Hospital in Steator, IL, who consulted on the case.
Sullivan says that another common problem with EMR documentation involves charting on children. He gives the example of an 8-month-old baby brought in for fever and vomiting. The review of systems states that the infant had no headache or vision changes. On examination, the infant's neurologic examination was "normal" and the box was checked that the child was "alert and oriented times three."
"How did the physician verify these facts with the infant? How did the physician determine that an 8-month-old was oriented to person, place, and time?" asks Sullivan.
While the infant's examination may in fact be "normal," physicians should be aware of what a "normal" designation causes to be printed on the computer, Sullivan adds.
Also, "on most systems, it is very easy to chart or order on the wrong patient. You are clicking from a list, usually on a small screen with an underpowered computer," says Robert B. Dunne, MD, FACEP, vice chair of the department of emergency medicine at St. John Hospital and Medical Center in Detroit.
Without Meaning to, You Lie
Like many institutions, Mineola, NY-based Winthrop University Hospital's ED is in the process of reviewing different EMR systems and will be implementing one of them in the near future. However, Audie Liametz, MD, JD, assistant medical director of the ED and chairman of the ED Quality Improvement Committee, says that one concern keeps coming up in each product. "The manner in which these EMR products create and document the medical record may give rise to a number of potential legal implications which plaintiff's attorneys are waiting to take advantage of," says Liametz.
Peter Viccellio, MD, FACEP, vice chairman of the department of emergency medicine at the State University of New York at Stony Brook, says that he has "huge concerns" with computerized records.
Viccellio says that it's commonly believed that EMRs are better for patients, but there is no evidence of this. "In fact, a number of studies show that medication errors increase after EMRs are implemented."1,2
Most of these systems originated as financial systems and were imported into the clinical arena, and aren't sophisticated enough for clinical care, notes Viccellio. "It's computer geeks trying to program a system that has to be used by health care practitioners," he says. "Although they can do many calculations, there are some simple things they can't do-like having a drop-down box that prevents you from accidentally clicking on the wrong choice."
Viccellio says that charts from transferring facilities with EMRs often bear no resemblance to the patient in front of him. "It's just a completely different story. It's also difficult to access the information because you have a 17-page chart for a two-hour visit," he says.
If an ED physician can check one box and it gives rise to a three page neurological exam, "without meaning to lie, you lie," says Viccellio. "If somebody comes in with a sprained ankle and they've got an eye exam, belly exam, heart exam, and lung exam-you don't really do that stuff. That's lying in the chart. Once you establish that, then anything in the chart is suspect. That, to me, is a big liability."
Here are medical legal risks of EMRs with risk-reducing strategies:
Nursing and physician notes may be inconsistent. The medical records and documentation in EMRs "can be quite voluminous," says Liametz. "The font size and the formatting of many EMR products, generally speaking, do not lend themselves to ease of clarity and navigation."
After the nurse checks off their documentation boxes, the physician may indicate something in their portion of the medical record that is contrary, without noticing these inconsistencies. "Time constraints in the ED and the quantity of information found in these EMRs could result in this type of inconsistent information being inadvertently displayed in the ED record," says Liametz. "This is yet another area of potentially fertile ground that might be used in a lawsuit to diminish the credibility and validity of what the practitioner has done with the patient."
Evidence of medical decision-making is lacking. Dunne says that "really, the risks of any template-driven chart are not different in the computerized medical record world."
"Template charting, with no specific history of present illness or medical decision-making, is often referred to as 'the plaintiff's dream,' and electronic records are no different," says Dunne. "Always personalize the record."
William J. Naber, MD, FACEP, an assistant professor in the department of emergency medicine at the University of Cincinnati, College of Medicine, says that "physicians or other health care providers will check, backslash or circle the boxes, but will fail to complete an adequate medical decision-making section."
Thorough medical decision-making can be invaluable when defending a malpractice case. "The logic behind what one did and chose not to do, as well as the differential diagnoses considered, is crucial for the defense attorneys to have," says Naber.
For this reason, always document the patient's chief complaint and the highlights of the history of present illness as a narrative in the chart. "On most systems, this is possible at the beginning of the document," says Dunne.
If you fail to make free script narrative entries or to do supplemental dictation, you can compare a hundred charts and not be able to tell one visit from another, says Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals.
"This will probably be of little value to you in defending a court case or responding to a CMS investigator," he says. "The record is 90% or more of what a physician will know about a case by the time it comes up six months or six years later. If your record is just a flat template description with no individualization, your memory of the case and your ability to defend it will be flat and dull also."
A summary that explains your findings, conclusion, and plan of care need not be long, "but often is the key to unlocking your memory and your defense," says Frew.
"To the jury, it suggests that you were actually involved with the case and cared about the patient rather than merely 'present.' Obviously, the more complicated the case, the more details you will want to note," says Frew.
Computerized "macros" add significant amounts of information to a medical record with one click. "While macros save time, they are often not 'one size fits all,'" says Sullivan.
"One must be extremely careful in how you set up your documentation formats and macros," says Liametz. "There is often too much inaccurate information that can be potentially documented by simply checking off a box here and there."
The practitioner must be careful to only check off the things that they actually did. "Otherwise, somewhere down the line if litigation ensues, the items that were incidentally checked off could come back to implicate the practitioner," says Liametz.
Dunne says that the risks in the ED "lie in the time it takes to chart. Most of the systems in use require typing to put in a unique history of present illness and medical decision-making. Even good typists lose time," he says.
Many voice recognition systems are time consuming and are often not supported by the hospital IT infrastructure. Studies of ED computer-based physician charting have shown about a 30% decrease in productivity, even after physicians learn the system, when compared to dictation and hand written charts.3
"This means the ED is more likely to get backed up. The pressure is there to get to the next patient, so documentation often suffers," says Dunne. "A good option is to continue to have dictation available for complex cases. Have the dictations added to the chart after transcription and review by the physician."
The wrong box-or the wrong patient-may be inadvertently checked. "Due to multitasking, time constraints and the fact that everything in the EMR is just a click away, one can accidentally and inadvertently check a wrong box," says Liametz. "In the handwritten world, this is less likely to occur. You have the 'hard copy' of the patient's record right there and you are writing what you are thinking."
Usually, the EMR lists patients either alphabetically or by bed location, but the wrong patient may accidentally be clicked on. "The hope is that you would catch your improper documentation," says Liametz. "But as with inadvertent checking of the wrong box, this too can occur due to time pressures and multitasking."
Warnings may not be given, or are easily ignored. One study noted that 90% of EMR warnings are clicked past because the user thinks they aren't relevant.4 Systems may also fail to warn users when they should.
"You cannot afford to ignore red flag warning pop-ups on the EMR," says Frew. "Evidence that you ignored a warning or failed to address a caution-especially without documenting the reason-can be devastating in a court case."
Your charting may fail to reflect what you actually mean to convey. "Although pressure is often on caregivers to move patients through the system as quickly as possible, it is helpful to think about what we chart before we chart it," says Sullivan.
For example, the word "normal" may mean different things to different people and may have different connotations for different patients. "Sometimes what we mean to say by checking a 'normal' box isn't what is reflected on the chart," says Sullivan.
For example, by checking that respirations are "normal" in a patient with chronic emphysema, a caregiver may intend to reflect that the patient's respiratory status is chronically compromised, but is stable. "However, someone reading the chart might get the false impression that the patient had no respiratory symptoms," says Sullivan.
Any part of the exam that is key to the chief complaint should be documented specifically, even if all are normal. "Using a 'within normal limits' check box is not helpful," says Dunne. "For instance in a head injury, I document the specifics of the head and neck exam with positives and negatives."
What you do not indicate can be a problem. "The EMR often has built in defaults, and not making an affirmative entry may generate a default entry," says Frew. "Be extremely familiar with the default entries and do not skip entries to save time. The result can be default entries that are contradictory, confusing, or plain wrong."
References
1. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 2005;116:1506-1512.
2. Bonnabry P, Despond-Gros C, Grauser D, et al. A risk analysis method to evaluate the impact of a computerized provider order entry system on patient safety. J Am Med Inform Assoc 2008;15:453-460.
3. Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of physicians and nurses: A systematic review. J Am Med Inform Assoc 2005;12:505-516.
4. Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med 2009;169:305-311.
Sources
For more information, contact:
Robert B. Dunne, MD, FACEP, Vice Chair, Department of Emergency Medicine, St John Hospital and Medical Center, Detroit, MI. Phone: (313) 343-7071. E-mail: [email protected].
Audie Liametz, MD, JD, Assistant Medical Director, Emergency Department, Winthrop University Hospital, Mineola, NY. E-mail: [email protected].
William J. Naber, MD, FACEP, Assistant Professor, Department of Emergency Medicine, University of Cincinnati, College of Medicine. Phone: (513) 600-4749. E-mail: [email protected].
William Sullivan, DO, JD, Frankfort, IL. Phone: (708) 323-1015. E-mail: [email protected].
Peter Viccellio, MD, FACEP, Vice Chairman, Department of Emergency Medicine, School of Medicine, Health Sciences Center, State University of New York at Stony Brook. Phone: (631) 444-3880. E-mail: [email protected].
When an ED physician was sued for allegedly missing signs and symptoms of a subarachnoid hemorrhage, the emergency medical record (EMR) documentation that was brought into evidence didn't help matters.Subscribe Now for Access
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