Could electronic records get your ED sued?

Risk of tools may not yet be known

Increasing numbers of EDs are implementing electronic medical records (EMRs), including computerized physician order entry (CPOE), with the goal of improving patient safety. However, not much is known about the liability risks of these new tools.

"We are still on the steep portion of the learning curve with regard to the medical-legal risks of CPOE," says Tom Scaletta, MD, FAAEM, chair of the ED at Edward Hospital in Naperville, IL. "It is a relatively new technology, and suits take years to come to fruition."

While electronic systems potentially can prevent errors, automation also can create a false sense of security. "There are no perfect CPOE or electronic charting systems," he warns.

The ideal documentation system is one that adapts to the user, says Scaletta. Your ED's system should offer a template style for past medical history, review of systems, normal exam findings, and diagnoses. It also should offer a free-form style for a description of the present problem, abnormal exam findings, medical decision making, and the treatment plan.

Whether electronic or paper template charting is employed, users should not be pressured to check every box just so the charges can be enhanced. To put a stop to that practice, Scaletta suggests doing an internal coding audit to identify and counsel outliers that might be embellishing charts. "The end result should pass the 'sniff' test," he says. "It is not realistic that a detailed family history has been obtained in every ankle sprain case."

Transition time is high risk

The benefits of CPOE are readily apparent: Handwritten and verbal patient care orders are no longer transcribed, so errors due to illegibility or nonstandard abbreviations are prevented. Additionally, alerts flagging medication interactions, allergy warnings, dosing limits, and order duplication can prevent other common errors.

However, during the initial phases of implementation, systems might not be fully functional, and safety mechanisms might not be put into place until later. For this reason, transition to an electronic system is a high-risk period for your ED. "While robust systems decrease errors on the whole, it can take months or years for systems to be adapted to meet the unique needs of the health care environment," says Scaletta.

In addition, until the system is fine-tuned, there may be a high rate of false-positive alerts. "Ignoring or overriding such alerts where a poor outcome results could be viewed as a more serious error by a jury," he warns. "If drug sensitivities are coded the same as life-threatening allergies, those false alerts get doctors accustomed to dismissing alerts."

Using a point-and-click method to rapidly choose an order can be fraught with inadvertent selection errors that might go undetected by the person carrying out the order. "Ideally, you should have a smart system that pairs the order with a complaint or finding," says Scaletta. "A low-tech solution is to alternate color coding of lines, like some spreadsheets do."

Initially, all systems will severely slow an ED's operations. To offset this, users should be well trained and EDs overstaffed until the system becomes familiar, he recommends.

Another risk with computerized systems is that physician-nurse communication becomes less active and more passive. "With CPOE, we can get out of the habit of a quick powwow," says Scaletta. "CPOE should not replace person-to-person communication in truly emergent situations. Time-sensitive or unusual treatments ought to invoke a direct physician-nurse conversation."

Scaletta recommends setting up electronic systems to create individualized care plans for some patients. Then, when the patient re-enters the system, the case can be flagged so the clinician is immediately directed to review the care plan. "We do this for any case that the care would be better should the team have a 'heads up,'" he says. This includes patients who failed to obtain follow-up care and reappear in the ED, patients with narcotic dependency, and patients with a history of unpredictable violence.

Processes for late charting and signing should be designed such that there can be no inappropriate alteration of medical records. "There should be the ability to record time-stamped addenda when information comes in later, such as a culture result, and requires modification of the patient treatment plan," says Scaletta.