Resource Library

Patient care documentation and order-entry in the EHR are key contributors to physician burnout. EHR systems may satisfy billing and reimbursement requirements, but generally fail at supporting clinicians in healthcare delivery. The burdens that EHRs introduce are compounded by the lack of certain functionality in existing systems.

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:

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.

Physicians should always consider how patients will react to seeing their own medical records. In the following case, sensitive information was prominently displayed in each office visit note in the printed out records. This issue became particularly upsetting to the patient when her records were released to her employer’s workers’ compensation carrier.

The following cases illustrate why it is important to edit records created by templates that default to normal and populate the patient encounter report with pre-composed text. When a template uses a limited set of phrases to describe various examination findings, many different patients will have identical text in their medical records. This became an issue in case two below, because the plaintiff’s attorney represented two different patients against the same physician. The attorney capitalized on the physician’s over reliance on pre-composed text in his patient records.