Could electronic medical records get your ED sued?
Risk of recently added tools may not yet be known
Increasing numbers of EDs are implementing electronic medical records (EMRs), including computerized physician order entry (CPOE), with the goal of improving patient safety. However, not much is known about the liability risks of these new tools.
"We are still on the steep portion of the learning curve with regard to the medical-legal risks of CPOE," says Tom Scaletta, MD, FAAEM, chair of the ED at Edward Hospital in Naperville, IL. "It is a relatively new technology, and suits take years to come to fruition."
While electronic systems can potentially prevent errors, automation also can create a false sense of security. "There are no perfect CPOE or electronic charting systems," warns Scaletta.
The ideal documentation system is one that adapts to the user, says Scaletta. Your ED's system should offer both a template style for past medical history, review of systems, normal exam findings, and diagnoses; and a free form style for a description of the present problem, abnormal exam findings, medical decision making, and the treatment plan.
Whether electronic or paper template charting is employed, users should not be pressured to check every box just so the charges can be enhanced. To put a stop to this practice, Scaletta suggests doing an internal coding audit to identify and counsel outliers that might be embellishing charts.
"The end result should pass the 'sniff' test," says Scaletta. "It is not realistic that a detailed family history has been obtained in every ankle sprain case."
Transition time is high-risk
The benefits of CPOE are readily apparent: Handwritten and verbal patient care orders are no longer transcribed, so errors due to illegibility or nonstandard abbreviations are prevented. Additionally, alerts flagging medication interactions, allergy warnings, dosing limits, and order duplication can prevent other common errors.
However, during the initial phases of implementation, systems may not be fully functional, and safety mechanisms may not be put into place until later in the process.
For this reason, transition to an electronic system is a high-risk period for your ED. "While robust systems decrease errors on the whole, it can take months or years for systems to be adapted to meet the unique needs of the healthcare environment," says Scaletta.
In addition, until the system is fine-tuned, there may be a high rate of false-positive alerts. "Ignoring or overriding such alerts where a poor outcome results could be viewed as a more serious error by a jury," warns Scaletta. "If drug sensitivities are coded the same as life-threatening allergies, those false alerts get doctors accustomed to dismissing alerts."
Using a point-and-click method to rapidly choose an order can be fraught with inadvertent selection errors that may go undetected by the person carrying out the order. "Ideally, you should have a smart system that pairs the order with a complaint or finding," says Scaletta. "A low-tech solution is to alternate color coding of lines, like some spreadsheets do."
Initially, all systems will severely slow an ED's operations. To offset this, users should be well trained and EDs overstaffed until the system becomes familiar, Scaletta recommends.
Another risk with computerized systems is that physician-nurse communication becomes less active and more passive. "With CPOE, we can get out of the habit of a quick powwow," says Scaletta. "CPOE should not replace person-to-person communication in truly emergent situations. Time-sensitive or unusual treatments ought to invoke a direct physician-nurse conversation."
Easy access to voluminous records can improve care, giving the ability to quickly check results of prior tests. "However, this may create unrealistic expectations," says Scaletta. "This wealth of information can suddenly cease during downtime periods."
Downtime procedures must be carefully designed and well-rehearsed, so that quality patient care can occur during such events. "The process of downtime procedures for accomplishing lab and radiology testing and printing discharge packets is very idiosyncratic, and needs to be carefully developed and tested at each institution," says Scaletta. "Many EDs revert back to a paper chart, with lists of the most common tests that can be check marked."
Scaletta recommends setting up electronic systems to create individualized care plans for some patients. Then, when the patient reenters the system, the case can be flagged so the clinician is directed immediately to review the care plan.
"We do this for any case that the care would be better should the team have a "heads up,'" says Scaletta. This includes patients who failed to obtain follow-up care and reappear in the ED, patients with narcotic dependency, and patients with a history of unpredictable violence.
Processes for late charting and signing should be designed such that there can be no inappropriate alteration of medical records. "There should be the ability to record time-stamped addenda when information comes in later, such as a culture result, and requires modification of the patient treatment plan," says Scaletta.
Inconsistent use is a problem
The EMR may be used inconsistently by various providers in your ED, which can increase liability risks. "All attempts to automate the ED have encountered this issue, including use of template forms and dictation," 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. "With each physician or nurse having their own style and a general resistance to standardization as 'cookbook medicine,' systems have great difficulty in achieving a common documentation structure."
With a lack of consistency, records become unreliable, sometimes unintelligible, and often legally inadequate. "We frequently see records where individuals mark templates and boxes using inconsistent marks that mean one thing for one provider and something else for another," says Frew. "It is similar to making up one's own abbreviation."
To ensure consistent use of the EMR, extensive training, constant monitoring, and administrative enforcement is needed. Quality monitoring should be focused on chart completion techniques, recommends Frew.
"Extra attention should be planned during the start-up phase of any EMR system to assure that all providers are invested in the new system," says Frew. "Retraining, incentives, and ultimately disciplinary consequences are likely to be needed to get full participation in the new system."
Another problem is that EMR printouts do not look anything like the screen versions, and are difficult for physicians and nurses to read and testify from in court.
"Lawyers are having to spend a great deal of time preparing witnesses for testimony in order to avoid issues in identifying the medical record and testifying from it," reports Frew.
While it is possible to get different format capabilities with various systems, the standard format is usually not user or court-friendly, says Frew. Where possible, printouts should be designed to give an appearance similar to paper records.
Setting defaults for when no entry is made can result in inaccurate information being documented, warns Frew.
In one example, a patient came into an ED with respiratory distress and was being managed with intubation. The final disposition was admission for ventilator management. The ED record in between those events, however, showed that the patient was alert and responsive, the throat was normal with no redness, there was no respiratory difficulty, and the patient was talking and relating history.
"How could this occur? Defaults," says Frew. "In this particular system, anything that the physician failed to change was entered as normal, with standard entries automatically generated."
The system did not force each box to be checked. The result was an ED record that would have been indefensible in court and would probably have been cited as an inadequate documentation of a medical screening examination by the Centers for Medicare and Medicaid Services (CMS) during an investigation of the Emergency Medical Treatment and Labor Act (EMTALA).
Another critical default concern is the time logging of entries. System approaches vary, but some systems time the entry when it is validated and not when the service was performed.
Extra effort is required to enter the actual time of service, but even then, the logged time will appear on the index as the time the entry was electronically signed. "This default can cause seriously misleading time entries that can compromise legal defense, quality monitoring, and root cause analysis," says Frew.
Frew suggests using a "Time Line Report" that orders the printout in time sequence. "This is a very important risk management option, as the first thing that is typically done with a file is to spend endless hours creating a time line of what actually happened," he says. "A quick report of the time line will help in quality, risk, root cause analysis, and court defense."
Time line reports list each event in the time sequence in which it occurred, combining information from various parts of the record into a sequence that can be readily understood to form an overview of the details.
"The time line often reveals whether care was rendered in the proper sequence and in timely fashion, or conversely, highlights sequence errors, timing issues, or inconsistent entries," says Frew. "It is a valuable tool in analyzing cases quickly and accurately."
Sources
For more information, contact:
- Tom Scaletta, MD, FAAEM, Chair, Emergency Department, Edward Hospital, 801 S. Washington, Naperville, IL 60540. Phone: (630) 527-3000. E-mail: TScaletta@aaem.org
- Stephen A. Frew, JD, Vice President-Risk Consultant, Johnson Insurance Services LLC, 525 Junction Road, Suite 2000, Madison, WI 53717. Phone: (608) 245-6560. Fax: (608) 245-6585. E-mail: sfrew@johnsonins.com