A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience
Issue link: https://innovationscns.epubxp.com/i/555782
[ V O L U M E 1 2 , N U M B E R 7 – 8 , J U L Y – A U G U S T 2 0 1 5 ] Innovations in CLINICAL NEUROSCIENCE 37 R I S K M A N A G E M E N T Information overload. EHRs can create too much information. There can be so much information that providers cannot find the pertinent information, or pertinent data could be overlooked. Amending data. This can be difficult. Also, given the fluid nature of an EHR, amending data can be misleading. In one case, the patient entered the hospital and indicated she had no known drug allergies. She was prescribed a medication for the first time and had an allergic reaction. The EHR was updated to list the allergy, but it updated it everywhere in the record, including in the admission notes. So it appeared as if she came into the hospital allergic to the medication that was prescribed, making the prescriber appear negligent. Templates. Templates create notes that look the same as every other note and may not create a record that is accurate for the patient and for the patient encounter. For example, there have been reports of adult templates used to document exams of children. Decision-support tools. Be aware that many EHR users complain that tools, such as safety alerts and clinical treatment algorithms, are not applicable to their treatment. To go through many inapplicable safety alerts leads to alert fatigue, which can result in a relevant safety alert being overridden without review. Lack of appropriate clinical algorithms became an important fact in one medical malpractice case 12 where the patient presented to the emergency department with complaints of severe calf pain and swelling. He was discharged with a diagnosis of viral gastroenteritis. Less than two days later, the patient died at a different hospital of necrotizing fasciitis. The court, in its opinion, placed the liability issue on the templates and decision support tools in the hospital's EHR and said: "The EMR templates are directed towards the chief complaint [which the doctor chooses] that also pertains to everything, your assessment and plan at the end of the chart. Here the chief complaint chosen by Dr. Kwon was fever, even though she acknowledges that Mr. Bowman did not have a fever at the time. She indicated that she had no option regarding the use of a template: you have to choose a template, and by that choice, a screen pops up and provides the doctor with other options or choices to make. So for example, there are different templates for other chief complaints, which include, as examples, ones for chest pain or abdominal pain. Further, the chosen templates have prompts as to certain medical information to be filled in…The resident who saw the patient in the emergency department said in a deposition that she was bound by the diagnostic system's templates for complaints that guide doctors' assessments and treatment plans." HOW TO STAY OUT OF COURT The case above illustrates that a provider's use of EHRs can lead to allegations of professional liability. The critical role of expert witnesses in malpractice litigation makes adequate documentation necessary. The expert will base his opinion, in part, on the record. The documented record stands as a testament of treatment provided and the reasoning behind it. Your documentation is your defense. Defensible cases where the provider delivered seemingly excellent care have been lost or settled because of poor documentation. Without documentation that supports the care that was given, it is difficult or impossible to find a supportive expert witness to help defend a case, thereby making it easier for plaintiff to prevail. The most powerful thing you can do in terms of having a defense in the event of a claim, lawsuit, or administrative action is to document the basis for your clinical decision making. In litigation, physicians' professional judgment carries a lot of weight. Courts will defer to the treating physician—as long as there is something to base that deference on, and that is your contemporaneous documentation. There is more than one way to treat a patient. Physicians use their clinical judgment in making treatment decisions. A physician can use proper clinical judgment and there may still be a bad outcome, such as a bad reaction to a medication. The bad outcome may not be a result of malpractice, but if a lawsuit ensues—what do we want to know? Why did the physician do what she did? How do we know that? We should know it from the record. Also, do not give a plaintiff's expert witness the opportunity to make up his or her own theory of why you made a particular treatment decision. State it in the record. Liability issues with EHRs include the following: Templates. Templates can cause all documentation to look the same. That can lead to credibility problems in the courtroom. Metadata. The computer keeps track of everything that is done, and how long it took to do it. Think about the problem of alert fatigue, i.e., there are so many irrelevant alerts that users just override all of them. In a particular case, if all alerts are just automatically overridden, and there is an adverse event, and that event could be tied to an alert, the computer will show exactly how long it took for the provider to override that alert. If the provider had alert