Electronic health records pose an array of dangers for physicians in terms of potential malpractice claims, according to a Medscape article.
"Anything could be a malpractice issue, from the product itself, to the way it was set up, to how you've been using it," Ronald B. Sterling, an EHR expert in Silver Spring, Maryland, and author of Keys to EMR Success, says in the article.
Among the potential dangers:
- Copying and pasting text – Easily uncovered by a plaintiff's attorney, it can be used to suggest you were not fully engaged in patient care
- Ignoring clinical decision support – The system logs how much time you spend reading alerts, so if something bad happens, it can be used to show you've skipped over the alerts
- Legal consequences of input errors – Sloppy documentation takes many forms. Perhaps the EHR did not provide a place for all information in the paper record. Some doctors don't sign their notes. Perhaps they check boxes that services were performed, but provide no documentation. All of that can be used to cast doubt on a physician's diligence.
"There are concerns with every single EHR feature, with every single capacity, and you need to think through them all and implement responsible stewardship," Sharona Hoffman, a professor at Case Western Reserve University School of Law, tells Medscape.
The Office of the National Coordinator for Health IT is working with the Joint Commission and others to educate clinicians about the possible role of health IT in creating unsafe conditions for patients. Too often, clinicians and risk managers don't see the role of health IT in adverse events, so they don't report it, panelists said at an ONC webinar.
Government and industry need to be involved in avoiding the "unintended consequences" of EHRs that affect patient safety, Sue Bowman, senior director of coding policy and compliance for the American Health Information Management Association, has written.
To learn more:
- read the MedScape article