One of the policies underlying the government's push to encourage adoption of electronic health records (EHRs) is the expectation that EHRs will help prevent medical errors. This view is held not only by health policy experts, but also malpractice insurers. In an earlier article, we explored incentives that some carriers are offering physicians to encourage EHR adoption. It is important to recognize, however, that some features of EHRs could actually cause problems from a risk management perspective if not properly addressed.
The primary goal of healthcare risk management is to safeguard the provider's assets from losses due to liability exposure. To accomplish this, a risk manager seeks to decrease the incidence of claims, and also to decrease the severity of loss. Loss includes indemnity payouts from settlements and judgments, and also defense expenses (attorney fees and other costs, such as expert witness fees).
In seeking to decrease incidence of claims, the objectives of risk management are harmonious with quality improvement. Both quality improvement and risk management seek to eliminate potential for medical errors.Medical errors can arise from many sources. While procedural errors (e.g., problems with surgical technique) can account for some adverse events, probably more errors arise from communication problems within the healthcare team. Examples include failure to timely communicate relevant clinical information among caregivers, which can cause delays in diagnosing the patient's condition; failure to highlight clinically significant events within the vast store of clinical data; or failure to identify patterns suggesting potential risk to the patient.
Because EHRs offer greater potential for organizing clinical data and making decision support immediately available to the clinician, the Institute of Medicine, among others, advocated adoption of EHRs, including computerized physician order entry (CPOE).As the health care industry has gained experience with EHRs, however, we have learned that EHR adoption can present its own problems.This is especially true with CPOE.A 2006 study found that unintended adverse consequences of several types could result from CPOE adoption. For example, when providers must select from long, dense drop down lists to choose the correct patient, it is easy to make an error without realizing it and enter orders for the wrong patient. For inpatient EHRs, the ability of physicians to enter orders from anywhere in the institution, or even outside, could result in multiple providers entering the same or potentially conflicting orders.
Recently, the Leapfrog Group announced that a simulation conducted by 214 hospitals found that their CPOE systems missed one-half of routine medication errors and one-third of potentially fatal errors. Nevertheless, the Leapfrog Group continues to advocate for adoption of CPOE. The study showed that nearly all hospitals were able to improve their performance by adjusting their protocols and running the simulation a second time. The Leapfrog Group suggests that hospitals should test and monitor their systems on a regular basis, and share information on best practices.
Features other than CPOE can also present challenges. While the EHR can contain massive amounts of clinical data, clinicians must navigate through multiple screens to access all the data and could miss clinically significant data contained in a portion of the record that the clinician does not routinely view, resulting in a failure to diagnose claim. Clinicians can misuse the copy and paste function of some record systems, continuing to insert earlier problem lists after the patient’s condition has changed.
As noted above, effective risk management seeks both to decrease incidence of claims, and also claim severity. If EHRs help to decrease inaccuracies or loss of documentation, this can help hold down liability costs. Documentation errors can make it necessary to settle even a defensible case, or can inflate jury awards. Paper records can be lost, documentation can be altered, and handwritten entries can be illegible. With the EHR, the record will not be lost (assuming that sound information security practices are followed). Thoughtful use of templates can prompt clinicians to record significant findings.
Electronic health records are not a cure-all for our defective medical liability system, and can present their own unique risks. However, on balance, EHRs can be an effective tool in helping to minimize liability costs.
 Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine, 2001.
 Campbell, Sittig, Ash, Guappone and Dykstra, "Types of Unintended Consequences Related to Computerized Provider Order Entry", J. Am. Med. Inform. Assoc. 2006; 13:547-556.
About the Author
Patricia King is a health care attorney in Illinois, and principal of the web-based business Digital Age Healthcare LLC (http://www.digitalagemd.com/).