Resource Library

Although electronic health records (EHRs) have many benefits, studies reveal unexpected patient safety and liability risks associated with their use. The speed at which EHR technology is advancing and the speed with which hospitals and medical practices are implementing these systems can partially explain this increased risk exposure.¹ Optimizing an EHR (using it to its full potential) can deflect some of this risk. However, the importance of optimizing an EHR can be overlooked amid the struggle to provide quality patient care while complying with regulations and participating in government incentive programs.²

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.