Most physicians now have firsthand experience with using electronic health records (EHRs) and are aware of the potential benefits EHRs offer to the healthcare industry.
The use of EHRs has increased rapidly since the federal government made an investment in the proliferation of the use of EHRs by passing the Health Information Technology for Economic and Clinical Health Act (HITECH) in 2009. Eight years ago, only 17 percent of doctors used EHRs. That percentage jumped sharply to more than half of all U.S. doctors using EHRs as recent as two years ago. By the end of 2014, about eight in 10 (83 percent) of office-based physicians had adopted the use EHRs in their practices. EHRs have arrived and are here to stay.
The potential benefits of EHRs are clear and desirable for patients and physicians alike. EHRs can provide physicians with quick and easy access to a patient’s history, prescriptions, lab results and other vital data, and they offer the potential for improved efficiency and accuracy in the management and documentation of patient records, which should translate into better patient care.
In practice, unfortunately, EHRs can be inaccurate due to unintended typos, inadvertent deletions, misinterpretation of drop-down menus or carelessness on the part of those responsible for entering patient data into the EHRs. Other causes for imprecise EHRs include the use of templates that auto-populate data, the practice of cutting and pasting from one EHR to another or multiple times in the same EHR, and the use of scribes who are not properly trained to input data into the EHR.
Mistakes in EHRs can lead to critical errors in patient care. For example, patients have been given incorrect doses, have undergone unnecessary surgeries and have been deprived of necessary care due to incorrect or missing information displayed on their EHRs. In 2015, a national publication reported about an elderly woman in Illinois who made a visit to an emergency room after she stabbed herself with a garden fork. A nurse in the emergency room clicked the “unknown/last five years” tab for the woman’s tetanus shot status, and to the elderly woman’s peril, the doctor interpreted the nurse’s selection to mean she did not need a shot. The elderly woman had never been immunized. She later died of tetanus and a medical malpractice lawsuit was filed on her behalf.
Medical malpractice lawsuits for poor patient care as a result of erroneous EHRs are a growing concern. At present, the incidence of medical malpractice lawsuits originating from errors in EHRs are relatively low overall, but EHRs have only recently become industry practice. Expect the number and percentage of medical practice lawsuits for mistakes in patient care due in part to inaccurate EHRs to rise rapidly within the next five years if physicians and healthcare providers in general do not take proactive measures to ensure precise input of data into their EHRs.
Finally, physicians should be aware that inaccurate EHRs could lead to enforcement actions for fraud. Centers for Medicare & Medicaid Services (CMS) is actively identifying and investigating EHR fraud. According to the Office of Inspector General, most EHR fraud is the result of either copying and pasting patient information into a medical record multiple times rather than updating the data appropriately or over-documenting medical information in order to bill more for services.
Physicians are encouraged to evaluate their EHR data input practices to improve patient care, which could thereby limit medical malpractice lawsuits, and avoid liability for healthcare fraud. Physicians can make an effort to ensure EHRs are accurate by:
- Providing education about appropriate documentation to staff;
- Reviewing EHR templates to ensure appropriate and correction documentation is encouraged;
- Conducting audits of documentation;
- Monitoring software to confirm it’s working properly; and
- Correcting any identified errors.
In 2012, the U.S. Department of Health and Human Services, together with the U.S. Attorney General, wrote a letter to the healthcare industry warning that, “False documentation of care is not just bad patient care: it’s illegal.” This warning remains true today in 2016 as the likelihood for errors in documentation has increased due to the now ubiquitous presence of EHR in the healthcare industry.
Cliff Robertson is an Associate and member of Strasburger & Price LLP’s Health Law Practice Unit in San Antonio. He can be reached at 210-250-6000.