Proponents of electronic health records (EHRs) like to claim the systems’ advantages over their paper counterparts—greater legibility, lifetime data storage, help with decision support and, ideally, accessibility by the patient’s entire clinical team—will lower the risk of medical errors and bad outcomes and, by extension, may reduce the number of malpractice lawsuits. Now a new study suggests that EHRs may do just that.
In a research letter published in June in the Archives of Internal Medicine, lead author Mariah Quinn, MD, MPH, clinical instructor of medicine at Harvard Medical School when she participated in the research and now an assistant professor of medicine at the University of Wisconsin in Madison, and colleagues point out that risk factors for malpractice suits include many of the events EHRs are designed to prevent, such as poor communication between providers, difficulty accessing patient information in a timely manner, unsafe prescribing practices and lower adherence to clinical guidelines (Arch Intern Med. 2012;172(15):1187-1189).
To determine whether there was a relationship between the adoption of EHRs and a change in the number of claims, the researchers studied closed-claims data from a Massachusetts malpractice insurer for physicians covered from 1995 to 2007, coupled with data from surveys administered to a random sample of physicians in multiple specialties in the state in 2005 and 2007. Of the 275 physicians who responded in at least one of the two years, 33 incurred 51 unique claims, 49 prior to EHR adoption and two afterward. Among otolaryngologists, the number of claims went from five prior to initiating EHRs down to zero afterward, a pattern that was repeated for many of the specialties observed. “We found that the rate of malpractice claims when EHRs were used was about one-sixth the rate when EHRs were not used,” the authors concluded.
Where Is Credit Due?
These findings were no surprise, senior author Steven R. Simon, MD, MPH, chief of the section of general internal medicine for the VA Boston Healthcare System, told ENT Today. “What surprised us was the magnitude of the effect. The data suggest that five-sixths of all malpractice claims could be eliminated if you had EHRs. That’s huge.”
Interestingly, the investigators could not trace this result to any specific feature of EHRs. “There are a number of ways in which these systems can reduce the likelihood of an error or a safety event,” said Dr. Quinn, “such as easily accessible medication lists that all providers can see, facilitation of communication among different specialists and built-in decision support to detect medication interactions that a provider might not have thought of. We’re just not able to say from our study what those specific things are.”
One attribute of electronic records is the “paper” trail they create. “I think EHR documentation has been one of many reasons for a decrease in the number of malpractice claims,” said Edward B. Ermini, MD, chair of the Medical Informatics Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). “The best defense against a lawsuit is good documentation and, if used properly, electronic medical records can help with that.”
Additionally, EHRs provide information that can prevent physicians from making mistakes. “What physicians do is make decisions, and the more information that’s available, the better those decisions are going to be,” said Dr. Ermini. The best systems, he said, give doctors the information they need to make good decisions, resulting in fewer errors that can lead to malpractice claims.
By prompting clinicians to enter information that might otherwise be overlooked or forgotten, the EHR system forces them to keep more thorough records and help track a patient’s satus over time. “If an EHR has a mechanism that reminds a doctor to do a routine or appropriate follow-up, it can prevent a missed diagnosis,” said Rodney Lusk, MD, president of the AAO-HNS, who has been working with electronic medical records for more than 15 years and authors the “Tech Talk” column in ENT Today. “For example, maybe a lesion was biopsied and turned out to be cancer, but the doctor didn’t get that piece of paper for some reason. It will be in the patient’s EHR.”
EHRs may also enhance doctor-patient communication, Dr. Ermini said. “When you have all the information in front of you and you can review it quickly before you see the patient, they feel that you know and remember what they told you at the last visit, and it makes them feel that they are being taken good care of.”
Rapid communication of lab and test results also make for happier patients and can be facilitated by EHRs, said Dr. Lusk. “If the lab results come in, I can communicate the findings to the patient through the web portal. I don’t have to waste time running the patient down, and they don’t have to waste time running me down.” The result: a happier—and presumably less litigious—patient.
The Other Side of the Coin
Not everyone is a fan of EHRs. “[Many of these systems] seem to have been designed by software engineers and computer scientists and often don’t address physician needs in a straightforward fashion.” said Charles Kossman, PhD, MD, a hematologist-oncologist in San Diego, Calif., clinical professor of medicine at the University of California San Diego and board member of The Doctors Company, a large malpractice insurer based in Napa, Calif. Among his gripes: limited compatibility among systems from different manufacturers and systems that shut users out after just a few minutes of inactivity or that move information to difficult-to-access areas after just a few days. “What if someone else has ordered a blood test for my patient four or six days ago and the system only keeps it as part of the immediate record for 72 hours? I can’t immediately access that information; I have to look for it in another part of the system,” he said.
In other words, he said, “EHRs can be time sinks, and the one commodity we physicians have less of than anything else is time.”
If anything, said Dr. Kossman, EHRs may increase the risk of medical errors. “Say I want to order a chemotherapy regimen on a dosing schedule individualized to a particular patient. My system does allow me to do that, but I have to modify something that someone else has established for me, and when I do that, I’m more apt to make a mistake.” He also cited the problem of “cloned” notes: “One doctor enters his own notes into the record. Then a second doctor sees that patient and, if nothing different has happened in the interim, he or she may cut and paste the first doctor’s note, perhaps adding one sentence. If that doctor has not read everything the first doctor wrote, they might put in something that’s incorrect, or they may miss the first MD’s point. So, many of us think there’s a lot of potential for malpractice issues.”
Other doctors echo his concerns regarding the temptation to cut and paste information. “There’s a real liability to just pulling data forward from past visits that aren’t meaningful to this particular encounter and may actually end up being wrong because things have changed, but they don’t get changed in the record,” said Dr. Lusk. “You have to take the time to review the information and ensure that it is correct, and busy clinicians may not always do that.”
But, he added, “that’s no different than what happens with paper charts that have been dictated. It’s still incumbent on you to go and read through it and, honestly, most of us don’t always take the time to do that. At least with EHRs, you get immediate feedback.”
Indeed, many of the criticisms leveled at EHRs, such as the time and trouble involved in looking for a specific piece of information or wading through old notes, also hold true for paper-based systems, said Dr. Simon. He conceded that system incompatibility remains an important challenge. “In a perfect world, every system would be able to communicate with each other freely, but that’s not a reason not to use EHRs. In my opinion, the benefits greatly outweigh the drawbacks.”
Otolaryngologists: In the Forefront…Or Not?
Opinions differ on how quickly otolaryngologists have entered the brave new world of EHRs. “I think otolaryngologists have been much quicker than average to adopt them,” said Dr. Ermini. “A lot of the early and current commercial systems came out of otolaryngology. The problem is that as we go to a national health information network, a lot of those early systems won’t mesh with the needs of that system and will have to be redesigned.”
Not everyone agrees. “I think otolaryngologists have not been early adopters of EHRs,” said Dr. Lusk. “They have kind of dragged their feet, largely because of the expense and the hassle involved. It’s really a pain putting in these systems, although almost everybody feels that once they have it, they would never go back.”