EHRs can wreak havoc on a practitioner's clinical documentation of patient care, exposing the provider to malpractice claims, warns HIT author Ron Sterling, in an article posted on hitechanswers.net.
"Regardless of the legitimacy of care and treatment, the inappropriate use of EHRs and/or EHR design vulnerabilities are exposing physicians to questions on the quality of care and physician due diligence," he writes.
Some of the EHR documentation issues cropping up that can adversely affect patient care include:
Transitioning from paper records
If the patient information transferred from paper to electronic form is not structured properly, the record will be faulty, Sterling warns. For instance, if a patient's history is not included correctly during the transfer, then it may not generate necessary clinical decision support tools, such as alerts.
Note signatures
Some EHRs automatically close a record after a set time whether or not the note has been signed; others remain open indefinitely. Both situations raise questions regarding whether the doctor authorized care.
Templates, default settings and cut and paste techniques
All of these can lead to errors by incorrectly populating a patient's record.
Patient note ammendments
An amendment made via free text may not end up showing up and refining the original note, so warnings based on the new information won't arise.
"Practices need to closely examine how the EHR is set up and used on a continual basis to maintain the efficacy of the patient records and efficiency of the practice," Sterling recommends.
The concern that EHRs and other health IT can affect patient safety has been on the forefront since the Institute of Medicine issued its report on the topic last November. A bill that would protect providers from malpractice and other liability if they used certified EHRs, entitled the Safeguarding Access for Every Medicare Patient Act is in the House Committee for Energy and Commerce.
To learn more:
- here's the blog post
- check out the IOM report
- here's the House Bill