Adopting EHRs offers many advantages to medical practices: increased productivity, better patient care and quite often, decreased liability risks. Not a lot of research has been done to establish a correlation between liability exposure and EHR adoption, yet many insurance companies will offer you discounts on your premium if you have an EHR. EDR features such as alerts, reminders, allergy and medication lists etc can help reduce the risk of adverse outcomes. In addition, doctors have an electronic document trail to furnish in case they do face a malpractice suit in court.
However, while EHRs can help mitigate some risks, they can also increase others and create entirely new ones as well. The same document trail that can be used as a defence can also show that a doctor never looked at a particular chart when prescribing medication. Since note creation and alterations are timestamped, lawyers can use it to claim that a nurse or doctor spent too little time examining a patient. The new alerts system could lull doctors into complacency and cause them to be less than thorough in looking over patient files. Similarly, the templates option, often a time-saving features, could lead users to ‘copy-paste’ information that was not meant to be included or cause errors to be duplicated for a long time before being corrected.
As a user of EHR systems, you should be aware of such pitfalls and take steps to guard against them. The most important precaution you can take is perhaps the hardest: do not assume that the EHR system will be comprehensive or 100% accurate all the time. While they will be fine for the average patient, there will still be plenty of outliers. Review all alerts and reminders and do not automatically accept or send them to patients.
You should also be careful not to change the form of data – original emails, reports received etc should be kept as they are and not transcribed in your own words. Don’t leave out any information that you would have once written down, even if it takes more time to enter it. Use templates only if it applies to that case and never just pick the ‘closest option’ in a drop down list if it’s not completely accurate.
No record keeping method is completely free of drawbacks. Keeping these issues in mind while selecting and using an EHR can save you significant time and expense should you ever have to face a liability suit in the future.