Clinicians and staff will find ways to work around aspects of an EHR system that are frustrating, time-consuming or inflexible. As the following case indicates, workarounds can generate errors, undermine patient safety and result in lawsuits.
Sending an electronic order with an incorrect dose was below the standard of care.
The patient presented to a specialist for an annual follow-up for his medical condition. For the past three years, he had been taking a medication for an off-label purpose without incident. As he had done in years past, the physician prescribed 30 2.5 mg tablets to be taken once per day, with enough refills to get the patient through to the next year’s exam. The physician assistant (PA) was tasked with transmitting the prescription order to the patient’s pharmacy. When the PA selected the prescription information in the EHR system, he was redirected to drop-down menus pre-filled with oncology-based doses of the medication. (The patient’s medication was FDA-approved for cancer treatment.) The PA was not presented with an option to select the dose or instructions ordered by the physician. He made multiple unsuccessful attempts to get the EHR software to transmit the off-label dose and instructions but it had been pre-programmed with set doses. Finally improvising, the PA chose the lowest dosage that appeared in the drop-down menu (two 2.5 mg tablets daily) and then typed the correct dose and instructions into a text box that appeared on the data field screen. The text box warned the content would not appear on the prescription. The PA unwittingly believed this meant the text box information would not appear on the patient’s medication bottle, but the pharmacist would see and consider the text box information when filling the prescription. He further believed the pharmacist would correct the dosage (to be consistent with prior prescriptions) or would call the physician to confirm the correct dosage based on the text box content. What the text box warning actually meant was the information in the text box would not be transmitted to the pharmacy.
The pharmacist who received the order filled the prescription as ordered, with directions to take two 2.5 mg tablets per day (twice the intended amount). The text box information was not transmitted, and he did not consider the prior prescriptions. The patient took the medication as directed on the medication bottle for a month, which resulted in permanent liver damage. He filed a lawsuit against the physician, the practice, the software vendor and manufacturers, and the pharmacy. Among his claims, he alleged:
- The physician was vicariously liable for the PA’s intentional transmission of the incorrect medication order.
- The practice was negligent for the selection, implementation and utilization of its EHR programs.
- The clinicians and staff were negligent because they knew the software was not working correctly, but they kept using it.
- The software vendor and manufacturers were negligent for the design, implementation and function of the programs.
- The pharmacy was negligent because it should have detected the dosing error before filling the prescription and should not have dispensed an incorrect amount of medication with incorrect directions.
The practice’s EHR vendor had installed software that integrated the EHR system and the e-prescribing system. The configuration allowed the group to transmit prescription orders to pharmacies using the EHR system interface. This saved the user from having to back out of the EHR system and enter the e-prescribing system every time a prescription was ordered. However, the integration software didn’t always work consistently, and sometimes the e-prescribing data fields appeared instead of the EHR system prescribing fields. Most of the time this did not present a problem, because the e-prescribing fields were the same as the EHR system fields. However, the e-prescribing software did not recognize standard dosage instructions for certain drugs that were used off-label, including the drug this patient used. When the PA attempted to re-order this medication, a template was brought up on the EHR screen that did not include dosage information previously programmed into the EHR system by the physician.
Although unusual, the problem with off-label prescribing was a known issue with this EHR system. The problem was being encountered more often because the practice had increased its use of e-prescribing to conform with the federal mandate. These glitches in the e-prescribing interface had caused various physicians and staff to bypass the EHR interface and enter prescriptions directly into the e-prescribing program.
During litigation, the software defendants were critical of the practice, its physicians and staff for developing work-around practices for problematic issues, errors and inconveniences. This, they claimed, deprived the vendor of the opportunity to corroborate and troubleshoot problems and to improve the integrated system’s functionality. Workarounds increased the likelihood of dosing errors, the software defendants said. They also accused the clinic of not using the EHR system the way it was intended to be used because staff at the clinic shared passwords and computers. (The clinic administrators were not aware this was happening — each staff member was assigned a computer and there were a sufficient number of computers for each staff member.) As is usually the case in medical liability lawsuits, finger pointing among the defendants complicated the defense. Because of negative standard of care reviews, the case was settled.
Medical Liability Risk Management Recommendations
More Information About Optimizing Your EHR to Manage Risks
- Closed Claim Case Study: Issues with Identical and Default Text When Using EHR Efficiency Tools
- Closed Claim Case Study: Pasted and Template Text In an EHR Leads to Problematic Medical Records
- Closed Claim CaseStudy: Uncorrected Default Text in an EHR Leads to Defamation Suit
- Closed Claim Case Study: EHR Integration Problems Contribute to Delayed Diagnosis of Lung Cancer
- Best Practices: Identify and Remedy EHR Liability Risk Issues: Risk Management Strategies
- Best Practices: EHR Best Practices — Lessons Learned in Litigation
EHR optimization can be a challenge for small practices without IT departments. In these circumstances, clinicians and staff must share the responsibilities of making an EHR operate appropriately. Consider the following recommendations:1,2,3,4
- Determine whether clinicians and staff are using workarounds to deal with computer glitches or inefficient processes.
- Evaluate the processes and determine how the problems can be fixed.
- Conduct a workflow assessment to identify problem areas before they become entrenched.
- Determine whether interfaces with outside systems (e.g., laboratories, transcription) need to be put in place. (Problems like this often can be avoided by ensuring compatibility with other commonly used systems prior to purchasing an EHR.)
- Identify which routinely used diagnostic vendors do not interface with the EHR and approach these vendors to develop an interface in order to facilitate receipt of results in an automated fashion.
- Determine whether interfaces that are in place are working effectively.
- Schedule meetings to discuss EHR usability.
- Encourage staff and physicians to determine and share best practices with one another.
- Discourage individually developed workarounds.
- Determine to what degree clinicians and staff are using available EHR features.
- On an ongoing basis, identify software training gaps and fill them.
- Retrain on a regular basis.
- Ensure that training includes using the EHR during the patient encounter.
- Utilize your vendor for available (usually free) webinars, online training, recorded training or guides about updates, upcoming modifications, and systems features you may not be aware of.
- Work with your vendor for EHR optimization and correction of unsafe software glitches.
- Formulate written EHR policies and procedures, and train all staff on the policies and procedures.
- Enforce EHR user best practices reflected in written policies and procedures and incorporate periodic evaluations of EHR use. (One of the problems in this case was determining how the change in medication dosage occurred. Because staff were sharing passwords and computers, it was impossible from a data entry perspective to determine who was ultimately responsible for sending the incorrect information to the pharmacy.)
- Formulate written EHR policies and procedures, and train all staff on the policies and procedures.
- Keep EHR software updated.
- Software updates often include fixes to address “glitches” and new features that can help your practice get more from your EHR.
- Create a practice-specific best practice EHR user manual that incorporates the general aspects of the vendor’s manual but includes approved shortcuts and uses specific to your practice. Not only will this help train new members of your healthcare team, it will serve as a repository of lessons learned during the process of implementation and optimization.
- Ensure that you have completed the initial implementation process and have confirmed the system is working the way it is supposed to be working.
- Most EHR systems are phased in gradually. Before you optimize your EHR, consider where you are in the implementation process.
- Set deadlines for effectively using advanced features that may not have been a priority during the initial implementation process.
- Be proactive. The root of user frustration may be lack of familiarity with the EHR features. Spend some time learning how to use the EHR — most systems allow for the creation of a tester patient.
1. SuccessEHS. 10 Things To Do After EHR Implementation.
2. Sittig DF, Singh H. A red-flag-based approach to risk management of EHR-related safety concerns. J of Healthcare Risk Mgmt. 2013;33(2):21–26.
3. Bowman S. Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications. Perspectives in Health Information Management. (accessed 6/12/17).
4. SuccessEHS. 8 Considerations for EMR Optimization.