Historically, the doctor-patient relationship has been at the heart of medical practice, with administrative tasks and record-keeping at the border.
Today, that critical balance is at risk. Nearly all hospitals and 80 percent of medical practices use electronic health records (EHRs), presumably to help improve access to health information and increase productivity. The problem is that none of these digital tools were designed specifically to advance the practice of good medicine.
Consider these stark statistics: Every hour doctors spend with patients, they dedicate nearly two more hours to maintaining EHRs and clerical work. Yet even when physicians are with patients, they’re spending approximately 37 percent of their time interacting with EHRs or other desk work.
We are now witnessing the highest levels of physician burnout on record. Indeed, the rise of documentation demands and decrease of meaningful patient interactions has led to major physician frustrations—while making it harder for physicians to deliver quality care.
For these reasons and more, the EHR has introduced patient safety risks and unanticipated medical liability risks. According to a new study from The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, the number of EHR-related medical malpractice claims has risen over the past 10 years.
For the most part, the EHR is a contributing factor in an EHR-related claim and not the primary cause. This and their low frequency (0.9 percent of all claims) suggest that EHRs infrequently result in adverse events of sufficient severity to develop into a malpractice claim.
When EHRs are a factor in a claim, the study showed that user factors (such as data entry errors, copy-and-paste issues, alert fatigue, and EHR conversion issues) contributed to nearly 60 percent of claims. As computer users, we all copy and paste. Therefore, it's no surprise that time-pressured physicians embrace the same habits when using EHRs. In fact, the University of California San Francisco Medical Center—today considered a top five medical center in the United States—reviewed more than 23,000 of their own progress notes over an eight-month period and found that, on average, clinicians manually entered just 18 percent of the text in each note, while 46 percent was copied and 36 percent was imported.
System factors (such as data routing problems, EHR fragmentation, and inappropriate drop-down menu responses) contributed to 50 percent of claims. EHR fragmentation was among the most prominent system factors, contributing to 12 percent of errors. This factor means that different components of a single patient encounter might not be located together in the EHR. Consequently, doctors must check in different places to find laboratory and x-ray results, histories and physicals, etc.—resulting in important information being overlooked or unidentified.
One overwhelming response to adjust to burdens introduced by EHRs has been the rapid growth of medical scribes. Nearly 20 percent of medical practices are using scribes to help untether physicians from the EHR, with many doctors citing improved efficiency and satisfaction. Yet while scribes can offer great advantages, they can be a double-edged sword. According to a survey of hundreds of physicians from The Doctors Company, the lack of standardized training and variability in experience among scribes poses risks to data accuracy and delivery of care—which could increase liability for the patient and physician alike.
With or without scribes, lowering risk begins with each patient visit. At the beginning of each new session, doctors should inform patients of the purpose of the EHR and emphasize they are listening closely even though they might be typing during the appointment. Practices can set up treatment rooms so the patient can watch the screen and see what is being typed. It is also helpful to summarize or read the note to the patient to demonstrate that you have listened, and ask, “Do I have it right?” If the doctor is using a medical scribe to untether them from their EHR, the same principle applies.
Patients must also become their own advocates. They can ask their doctor to read back the EHR notes or review what has been written. Patients can interact with their health record online through patient portals and review their medical record as well as disease-specific educational materials and drug safety information. It is important that they communicate any errors they find as well as personal information updates to the physician.
As with any challenge of major proportions, progress will take time. But I'm optimistic that the EHR will evolve over the next 5 to 10 years and improve both the quality of medical care and patient safety.
Optimizing the EHR will involve:
Today, what I hear from The Doctors Company’s 80,000 member physicians is encouraging. Doctors are eager to “reclaim” their profession and refocus patient relationships amidst the new demands of today’s digital age. Into the future, new protocols, policies, and training programs must take these small successes to a large scale.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.