Identify and Remedy EHR Liability Risk Issues: Risk Management Strategies

NORCAL’s risk management specialists were asked to provide EHR liability risk issues they were seeing in the field. In addition to the issues covered in the EHR case studies presented in the March 2014 issue of Claims Rx, their list included:

• Open progress notes
• “Note bloat”
• Follow-up delays
• Lack of after-hours call documentation

The following strategies are provided to identify and remedy these issues.

The Risks of Leaving Progress Notes Open in Your EHR

Some EHR systems allow progress or office visit notes to remain open until users “close,” “finalize,” or mark as “done” the note in the system, but they do not have an automatic lock-out timeframe if these actions are not completed. This can result in late entries, not documenting patient encounters contemporaneously, manipulation of or changes to a medical record entry, and/or even letting multiple clinicians contribute to a patient note under one identifier. Inappropriate late entries and record corrections can turn what may have been a defensible claim into one that has to be settled, even when the recordkeeping did not contribute to the patient’s injuries. Additionally, as the NORCAL EHR case study “The Problem with EHR Workarounds” indicates, notes that are not closed and that allow data changes under a single identifier make it very difficult to determine who is responsible for a prescription error. This not only complicates corrective actions and defensibility of a malpractice claim but also compromises the integrity of the entire medical record. Consider the following documentation strategies:

• Never share passwords.
• Ensure that the EHR system dates, times and authenticates all entries in the patient record.
• Ensure that each patient visit entry is closed, becomes unalterable and is authenticated within a specified timeframe after the patient visit and prior to billing for the encounter.
• Develop written policies and procedures defining standards for the timely sign off and locking of patient visit encounters.
• Define the problem of open encounters and determine how to manage individuals who chronically fail to close encounters.
• Consider running monthly reports to review medical records encounters that have not been closed within the written and defined timeframe.

Beware of “Note Bloat” When Documenting Medical Care

“Note bloat” refers to ponderous and repetitive information in a progress note that has been generated by an EHR. Although it is important to keep liability risk management, billing, research, compliance, etc. in mind when documenting medical care, the principal clinical mission of a progress note is to promote quality patient care and to facilitate coordination of care among other healthcare team members. Conceptually, a progress note should be factually correct, temporally relevant, concise, analytical and reflective of collaboration.¹ It is difficult and time consuming to locate significant clinical information in a bloated progress note. These notes can also discredit physicians in litigation because the notes seem overblown and impersonal. Consider the following strategies to avoid note bloat:²

• Use free text to describe the patient. If it is too difficult to type up why a patient presented for treatment, find a way to dictate crucial information. Think of what you would like to review yourself in a patient’s record and use that as a guide for relevancy. For example, many patients do not need a complete review of systems (ROS).
• If self-populating templates are unavoidable, go through final record entries and ensure that they accurately reflect the patient’s condition and systems you have actually evaluated during the encounter. Make necessary corrections before making your current entries a part of the patient’s permanent record.
  • Consider periodically reviewing a printout of a note and assessing it from an auditor’s, another clinician’s or expert witness’ viewpoint:
    • Is it easy to understand and evaluate your note?
    • Does the note accurately describe what you did for the patient?
    • Does the note support your billing?
    • Did the note pull in necessary data from other tabs or screens?
    • Did the system insert unnecessary or even incorrect generic information (e.g., “alert and oriented to person, place and time” for a newborn patient)?
  • Create varied exam templates for different patient complaints and conditions.

While you may be tempted to take advantage of timesaving features provided by an EHR auto-population feature, patient safety and clinical accuracy should be the primary focus of documentation.

Avoid Follow-Up Failure and Delays When Using an EHR

Faulty computer functions or incomplete or incorrect EHR use can result in treatment delays or failures. For example, some practices may have EHRs, but they do not use the ordering functions, the reporting functions and/or the tickler systems that track missed or canceled patient appointments, missed test results and/or referral reports. Consider the following strategies:

• Review your follow-up, tickler, and tracking policies and procedures and ensure they close the loop (from order to patient receipt of results) and are tracked within the EHR.
• Develop and run aggregate reports to analyze follow up and tracking within the practice. For example, reports that track the number of overdue results or the number of outstanding items in providers’ or medical assistants’ inboxes can be used to measure workflow effectiveness within the practice.
• Use the EHR “tickler system” and reporting capabilities to their full capacities.
• Devote extra scrutiny to the safety of follow-up systems that rely on a combination of EHR and paper.
• For non-interfaced results, immediately scan reports into the EHR and forward them (or “task” them) to the clinician the same day they arrive.
• If study results are sent to physician inboxes, enforce a policy of checking inboxes at appropriate intervals and communicating results to the various parties who need to see them. Consider running reports to evaluate the volume of tasks in inboxes.
• Ensure that patient health information is clearly forwarded (or tasked) to a designated individual. (An EHR may disseminate patient information to multiple clinicians at once, resulting in unclear responsibilities).

Steps in the follow-up process can be delegated to staff; however, it is ultimately the physician’s responsibility to ensure that appropriate follow-up occurs.

Be Diligent about After-Hours Call Documentation

Even though EHRs usually allow physicians to have remote access to patients’ records, inadequate after-hours call documentation continues to be a problem. Consider the following recommendations:

• Create a protocol for documenting after-hours communications with patients.
• When possible, contemporaneously enter documentation of after-hour patient interactions directly into the EHR.
• Ensure that the patient’s primary physician is aware of the after-hours encounter.
• If EHR access is not available, keep notes and enter patient health-related data as soon as the EHR becomes accessible.
• If applicable, use reports of calls generated by the answering service to double check that all calls received after hours are followed up and documented.

References

1. Lipton M, Press R. “Electronic progress notes – Avoiding note bloat and other pitfalls.” April 1, 2010.

2. Nicoletti B. “The EMR template: I want to believe.” February 15, 2013. (accessed 6/12/2017)