Electronic health records contain features, such as templates, which can help providers reduce the risk of malpractice litigation. But the misuse of EHRs actually can cause providers to be more vulnerable to such lawsuits, according to a recent article in MDNews.com.
An EHR's audit trail function, which keeps track of the date and time of all activities performed on the EHR, can become a malpractice liability, the article points out. For example, if a physician treats a patient and weeks later realizes he left information off of the patient's chart and signs on to add it, the date and time of the amendment will be logged on the audit trail, which can be used against him. Or, since the EHR tracks access to the records, if a provider failed to review data--such as test results that had been received--it's relatively easy for the patient's attorney to discover that omission.
Mistakes, such as sloppy cutting and pasting, also can cause the records of one patient to end up in another patient's chart, warns Marc Resnick, professor of Human Factors and Information Design at Bentley College in Waltham, Mass. This creates inaccurate or conflicting records that can lead to the wrong treatment decisions.
Risk reduction plans, according to the MDNews article, should consist of the following :
- Scheduling additional time to become familiar with the practice's EHR system to prevent documentation errors;
- Adapting to changes in standards of care created by the EHR, such as reading pop-up alerts;
- Explaining inconsistencies in documentation. Adding a detail to a record later is fine, so long as providers include a reason for doing so.