Most adults are old enough to remember going to the doctor’s office and seeing their doctor flip through the pages of their chart, looking at their history, gathering information that was right there at their fingertips.
These days, your doctor may still look through your chart, and the information may still be at their fingertips. But rather than flipping through sheets of papers, test results, and notes, your doctor may be looking at a tablet computer, on which your record (and hundreds of others) is available at the tap of a screen.
In fact, since 2014, federal law has mandated the use of electronic health records (EHRs) by doctors and other health care providers. On the surface, EHRs seem like a great idea. Doctors are stereotyped as having illegible handwriting. That can lead to a pharmacist supplying the wrong medication based on a scribbled prescription, sometimes with lethal results. Difficult-to-read orders can also lead to nurses administering the wrong treatment, or even an overdose, to a hospitalized patient. In short, doctors’ famously poor handwriting has led to numerous medical malpractice claims.
EHRs would seem to be a solution to the problem of illegible records. EHRs are intended to improve quality of care and reduce mistakes. But do these records carry their own risks of medical malpractice? Perhaps surprisingly, the answer is that they do.
To be clear, EHRs do have a lot of benefits, not the least of which is that information entered into a record is going to be legible. But there are also risks that are not present with handwritten records.
For one thing, with a handwritten record, the amount of notes a doctor can take is necessarily limited. With EHRs, notes tend to be much more lengthy, and not only because it is faster to type than to write. Doctors can, and often do, “copy and paste” blocks of text. That can result in documentation of examinations that didn’t actually happen or were not as thorough as the note might suggest.
A note from one visit may be copied and pasted to the next, identical except for the date. If there is genuinely no difference, that’s fine. It is possible that a patient had no complaints and that an examination revealed nothing troublesome. But it can be difficult to know whether that is really the case, or if the doctor, in order to save time, simply copied and pasted previous findings. Some malpractice attorneys have discovered that doctors they were investigating copied and pasted exam notes when the notes were identical word for word, right down to the same typographical errors in the same places.
If you have ever been in an exam room with a doctor using an EHR, you may have had the experience of her turning her back on you, or at least breaking eye contact, while she took notes. Recording information in an EHR can be time-consuming, and entries into the system are time-stamped, so many doctors do it during the appointment. This can lead to a poor-quality exam. Doctors may be more focused on documentation than examination. Also, patients tend to be less forthcoming when it appears their doctor is not paying attention to them, and doctors may fail to notice cues when they are not looking at their patient.
Sometimes, copying and pasting makes sense, such as when describing the patient’s previous medical history. The past doesn’t change. But doctors should not take this shortcut when documenting a current exam. Unfortunately, due to time pressures and (ironically) the fear of litigation, many doctors do, anyway.
There are other ways in which electronic health records can contribute to medical malpractice. Technology failures can result in the loss of information or the entry of incorrect information. If you’ve ever selected the wrong item from a pull-down menu online, you can understand how a doctor might inadvertently select a too-high dosage from a list when prescribing a medication. If you’ve ever had your phone “autocorrect” to a word you didn’t mean, you can understand how a doctor creating a prescription might accidentally order the wrong medication, that starts with the same few letters as the one he intended to order.
Fragmentation of records can also be an issue. Many patients may have existing paper records, and newer EHRs with the same providers. Unless the entire paper record has been transcribed into the EHR, there can be information gaps—and some of that missing information can be critical to the patient’s ongoing care.
Over the last decade, EHR-related malpractice claims have been on the rise. Some result from user error, like copying and pasting, and others from technology failures. If you suffered harm that you think may have been related to your doctor’s use of electronic health records, you should consult with an experienced Oregon medical malpractice attorney.
The information in this blog post is provided for informational purposes only and is not intended to be legal advice. You should not make a decision whether or not to contact a qualified medical malpractice attorney based upon the information in this blog post. No attorney-client relationship is formed nor should any such relationship be implied. If you require legal advice, please consult with a competent medical malpractice attorney licensed to practice in your jurisdiction.
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