Hidden Malpractice Dangers in Your EHR

Ron B. Sterling, MBA, CPA

Disclosures

March 25, 2016

In This Article

Don't Let a Powerful Ally Become a Double-Edged Sword

Generally speaking, medical malpractice claims are based on harm to a patient where the treatment falls below the standard of care. Electronic health records (EHRs) can pose serious malpractice problems because EHR initiatives are changing the standard of care.

For example, most physicians probably have an EHR system that checks for drug-drug and drug-allergy interactions (a meaningful use measure). Similarly, secure messages from patients through your system's patient portal may present important information that affects your care strategy and the advice you give to the patient. Failure to properly address any problems or record the information in the EHR may lead to a lapse in care.

Although EHRs can serve as your best defense against a problem that could evolve into a malpractice claim, they can also have the opposite effect. That's because EHR-based tools offer a level of detail about how and when you managed a patient situation—all of it information that's available to a plaintiff's counsel in a lawsuit. Such information may prove that the physician or healthcare organization provided appropriate and timely care, or it may seriously undermine the physician's ability to prove due diligence and professionalism. The difference between the two outcomes is contingent on how effectively you use the EHR tools available to you.

In order to capitalize on the EHR to provide effective patient care, as well as avoid situations that could lead to a claim, it's important to take these steps:

1. Get Everyone on the Same Page

Proper use of the EHR must be verified and approved by the physician-owners of the practice or by the medical leadership of the healthcare organization. Unfortunately, in many small practices, as well as in large organizations, the EHR vendor and its technical staff drive how certain features of the system are presented and used, without adequate consideration of the clinical and patient service issues.

For example, the vendor's patient documentation tools may be used "as is" even though the checklists don't cover the key services your practice or organization provides. Indeed, technical staff and trainers may not be familiar with the operational nuances of various areas of medicine. For example, primary care practices need tools to monitor patients who are referred to specialists.

The clinical leaders in your practice should verify what the EHR system is capable of, and staff training should focus on meeting the organization's documentation standards. The practice should create its own training materials with information on how to use the EHR most effectively, including how to document various situations and services.

For example, the support staff of a surgical practice should know how to enter a surgical order into the EHR, as well as how the scheduling team tracks patient surgeries that aren't included in the base EHR product. Similarly, all practices should discuss the mapping of the patient history forms (whether on paper or posted on an online patient portal) to the clinical note and minimum documentation requirements.

Standards are important because all users need to understand the baseline information that's in the patient records and how the EHR uses this information.

Risk Reduction Strategy: The practice's leadership should document the verification of all clinical information, test results, and follow-up efforts.

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