Records containing information from the wrong patient or inaccurate template-generated or pasted content are just some of the difficulties that can arise when using EHR efficiency tools improperly. As the following cases show, it can be difficult to defend otherwise acceptable care with problematic medical records.
Case One: Late Corrections of Pasted Content
The following case illustrates the difficulties associated with defending medical care with records containing information from the wrong patient.
Allegation
The physician gave the patient a copy of her record before correcting information copy/pasted from a different patient’s record.
Case File
A family physician (FP) was treating a patient with an ACE inhibitor and lithium. The patient did not get her blood tested as often as recommended, but the FP continued to refill her prescriptions. One afternoon, the patient presented with a dry cough and nausea. The FP ordered blood tests and recommended over-the-counter remedies for what he thought were probably cold symptoms. At the end of the visit, the patient asked for a copy of the office visit note. Prior to the patient’s visit, the FP had pasted some information from a similarly situated patient’s record into hers, with the intention of making edits following the examination. In this case, the FP printed out the office visit note and gave it to the patient before he cleaned it up. Days later, the patient was transported to the emergency department (ED) and diagnosed with lithium toxicity. Shortly after that, the FP finalized the office visit report. In her lawsuit against the FP, the patient claimed she suffered permanent brain damage from the FP’s failure to adequately monitor the lithium.
Discussion
Although defense experts were critical of the FP’s failure to monitor both the lithium and the ACE inhibitor, they felt that the patient’s noncompliance significantly contributed to her poor outcome. The defense team planned to take the case to trial if the patient did not decrease her settlement demand. This strategy was working well until the patient’s attorney noticed that there were two different versions of the “cold symptom” office visit record — one given to the patient and the other printed from the permanent record. The plaintiff’s attorney alleged that the FP made self-serving corrections to the record after he discovered the patient had developed lithium toxicity. The defense team concluded that the records issue would destroy any chance of a defense verdict at trial. Therefore, the case was settled.
Case Two: Multiple Corrections of Pre-Composed Text from a Template
Before EHRs, intentionally sending an inaccurate procedure report to subsequent providers was rare. Now, because of incorrectly used templates, it is not that unusual. If the gastroenterologist in the following case had known how to send an accurate, brief note explaining that he discovered an esophageal perforation at the very beginning of an upper GI endoscopy, a dismissal of the negligence claim against him might have been possible.
Allegation
The physician distributed three different printouts of the patient’s operative report, which included varying amounts of irrelevant template-generated content, before he completed and signed the final report.
Case File
A patient presented for an upper GI endoscopy at an endoscopy center. Shortly after passing the endoscope into the esophagus, the gastroenterologist cleared some debris and discovered a perforation. He stopped the procedure and ordered a transfer to a nearby hospital. Because the gastroenterologist wanted a procedure note to accompany the patient, he pulled up the “routine/normal upper GI template” in the EHR and added his impression — that the patient had an esophageal perforation. He did not disable the template default settings. Consequently, the report he sent with the patient (Report 1) indicated the endoscopy had been completed and all of the structures that would usually be visualized during an upper GI endoscopy were normal.
Shortly after the patient had been transferred, the gastroenterologist became concerned that the first report would be confusing to subsequent treating physicians. He therefore printed out another report (Report 2), drew lines through all of the structures that he had not visualized and faxed the report to the hospital. Later in the day, the endoscopy center EHR prompted the gastroenterologist to sign off on the operative report. He added his observations and disabled the default settings (Report 3). A month after the procedure, the patient requested his records from the endoscopy center, and he was sent the existing record (i.e., Report 3). After the records were sent to the patient, the gastroenterologist further refined his documentation of the procedure (Report 4). After the final record correction, the patient filed a medical liability claim against multiple healthcare providers, including the gastroenterologist, who he claimed had negligently perforated his esophagus.
Discussion
The defense experts in this case felt the gastroenterologist had met the standard of care in his performance of the endoscopy. However, the defense of the gastroenterologist became complicated because four different versions of the endoscopy report were produced during litigation. The hospital produced Reports 1 and 2. The plaintiff produced Report 3, and the endoscopy center produced Report 4, which was the current version of the operative report in the EHR. The existence of the four different procedure notes might have been immaterial; however, the plaintiff’s gastroenterology expert suggested that the multiple corrections were evidence of a cover-up of the fact that the gastroenterologist had perforated the patient’s esophagus during a complete upper GI endoscopy. Because of the documentation problems and other issues, the case was settled.
Case Three: Failure to Correct Pasted Content
In the following case, pasted content from different patients’ records was never corrected, which diminished the defensibility of a subsequent malpractice claim because it made the defendant physician appear disorganized and careless.
Allegation
The plaintiff’s medical record contained information from different patients.
Case File
In April 2012, a new patient presented to an FP with complaints of right knee pain. The FP’s impression was internal derangement. He ordered an MRI and blood tests, prescribed anti-inflammatories and pain medications and told the patient to follow up with him in one month. The patient’s blood test results indicated high cholesterol and diabetes. She did not get an MRI. At her follow-up appointment in May 2012, the FP prescribed cholesterol medication, but never addressed her diabetes. The patient continued to follow up every month for unresolved knee pain. Her pain and cholesterol medications were regularly renewed. In January 2013, the patient presented to the ED for severe knee pain. She was admitted after a bilateral lower extremity angiogram demonstrated significant occlusive disease to the popliteal artery above her knee. Interventions failed and she had a below-the-knee amputation. The patient sued the FP, alleging his failure to diagnose and treat her diabetes resulted in the amputation. She also sued the hospital physicians for negligent treatment.
Discussion
Experts were critical of the FP for failing to treat the patient for diabetes. During litigation, however, defense attorneys discovered that the patient had been treated for diabetes many years earlier, but she had not been compliant with monitoring or treatment. They attempted to get the FP dismissed from the case based on a combined causation and contributory negligence defense. They argued that the patient would have had the same outcome regardless of the FP’s failure to treat her diabetes, because her occlusive disease was well-developed by the time she started treatment with the FP, and she would not have been compliant with diabetes treatment had it been recommended. In response, the plaintiff’s attorney pointed out multiple irregularities in the patient’s medical record. For example, the FP had been copying and pasting demographic information from other patients’ records, which resulted in incorrect addresses, heights, weights and Social Security numbers in the patient’s record. The plaintiff’s attorney was expected to call attention to the incorrect entries to portray the FP as disorganized and careless, which could cause the jury to doubt his testimony about appropriately examining the patient’s leg. The case was ultimately settled due to the combination of unsupportive expert reviews and poor documentation.
Risk Management Recommendations
Although cloning may seem to be a necessary time-saving strategy, it should not be done inappropriately, recklessly or automatically. Consider the following recommendations:1,2,3,4
Recommendations for Physicians’ Use of EHR Efficiency Tools
- Avoid copying and pasting from one patient’s medical record to another.
- Carefully review and update any pasted content prior to finalizing the record or providing the patient with a printout.
- Consider the consequences of distributing an inaccurate patient report.
- Know your practice’s protocol for making corrections to patient records and follow it.
- Only Copy/Paste* what is relevant to the patient encounter.
- Judge the relevancy and appropriateness of the pasted content when it is in the new record.
- Don’t paste information into the record simply because it is available. (E.g., if the fact of an ovarian cyst’s existence is what is relevant, the MRI reports may not belong in the examination note.)
- Use free text instead of Copy/Paste when it is appropriate. If you are spending an excessive amount of time deleting and correcting information that is automatically being generated, or that you have pasted in or carried forward from other records, use of the Copy/Paste tools isn’t increasing your efficiency.
Recommendations for Administrators’ Use of EHR Efficiency Tools
- Let EHR users know how Copy/Paste can endanger patients and increase liability risk.
- Create and enforce clear policies, rules and instructions for Copy/Paste.
- Balance needs for clinical efficiency with clinical accuracy in documentation.
- Do not tout Copy/Paste as a means of improving clinician productivity.
- Include Copy/Paste protocols in EHR training.
- Train physicians specifically for EHR features and processes that are most important to them.
- Seek physician input into training design and scheduling.
- Repeat EHR training regularly.
- Assess whether physician users have mastered basic use of the system. When they have, introduce advanced features that can make EHR documentation more efficient.
- Train physicians specifically for EHR features and processes that are most important to them.
- Audit records generated from the EHR and provide feedback to users on documentation practices.
- Address dangerous Copy/Paste practices before they become ingrained.
- Understand why users are engaging in inappropriate Copy/Paste.
- If Copy/Paste is being utilized inappropriately because the process of creating the patient record is onerous, consider how the process could be made easier for providers who are struggling (e.g., weak typists may benefit from the use of voice recognition software or a scribe).
- Modify the EHR system to decrease inappropriate Copy/Paste practices (e.g., insert prompts that require users to review and update pasted text).
- Create policies and protocols for EHR correction. Ensure that the system clearly indicates the times when corrections were made, what was changed or added and the identity of the person making the changes.
* As used in this case study, the capitalized term “Copy/Paste” refers to various techniques used to move text around in medical records, including “pulling forward” (a patient’s prior medical information used as part of a new record) and textual copying and pasting.
References
1. Dimick C. Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk. Journal of AHIMA. 2008;79(6): 40-43. (accessed 6/16/2017)
2. Hirschtick R.“Sloppy and Paste.” Web M & M: Morbidity & Mortality Rounds on the Web. 2012 July. (accessed 6/16/17)
3. O’Reilly, K. EHRs: “‘Sloppy and paste’ Endures Despite Patient Safety Risk.” American Medical News. 2012 Apr 4.
4. Shepherd A.“The Perils of Copy-Paste.” For the Record. 2011 Mar 14. (accessed 6/16/2017)
