EHR templates: Time-saver or patient safety risk?
Enhanced oversight capabilities, combined with potential cost efficiencies and quality-of-care improvements, have led to the federal government's carrot-and-stick approach to EHR adoption. The federal government has extended $27 billion in Health Information Technology for Economic and Clinical Health Act incentive payments to assist in the transition to digitized, interoperable record systems. But by 2015, all records must be electronic at the risk of reimbursement reductions from Medicare and Medicaid and, sure to follow, private insurers.
So why has the Institute of Medicine (IOM), an independent organization that advises that same federal government, called for the formation of a federal entity to monitor and investigate patient deaths and injuries resulting from improper use of EHRs?
The answer is in a study by the IOM, released November 8, which states, "Poorly designed, hard-to-use computerized health records are a threat to patient safety."1 EHRs a threat to patient safety? We have discussed, in past columns, patient safety issues that can arise from over-reliance on the clipnical support system in computerized physician order entry (CPOE), "cloned" notes, and failure to review and act on the information available in the EHR. A recent patient death and ensuing lawsuit in New York demonstrates that a poorly designed template for entering progress notes or history and physical, or over-reliance on templates that may be useful and well-designed, can create precisely the type of patient safety issues that become lawsuits.
EXPOSURE TO LIABILITY
The case of Bowman vs. St. Luke's-Roosevelt Hospital Center,2 a medical malpractice lawsuit in New York County (Manhattan), may serve to demonstrate liability exposures created by EHRs.3 In the Bowman case, a patient presented to the emergency department (ED) with complaints of severe calf pain and swelling. The pain, the patient stated, was worse with movement. He was discharged with a diagnosis of viral gastroenteritis. Thirty-six hours later, Mr. Bowman died at a different hospital. The cause of death was necrotizing fasciitis. The court succinctly placed the liability issue in the case on the use of templates in the hospital's EHR, as follows:
"[The EMR] templates are 'directed towards the chief complaint [which the doctor chooses] that also pertains to everything, your assessment and plan at the end of the chart.' Here the chief complaint chosen by Dr. Kwon was 'fever,' even though she acknowledges that Mr. Bowman did not have a fever at the time. She indicated that she had no option regarding the use of a template: 'you have to choose a template,' and by that choice, a screen pops up and provides the doctor with other options or choices to make. So, for example, there are different templates for other chief complaints, which include, as examples, ones for chest pain or abdominal pain. Further, the chosen templates 'have prompts as to certain medical information to be filled in.' "4
The implication—indeed the salient claim in the case—is that the template limited the entry of information and differential diagnosis choices. This limitation is fairly common. EHR vendors, in the interest of making their products affordable and easy to use for most conditions, do not and, practicably, cannot create a template for every disease, process, or condition.
And that, indeed, is the potential liability exposure with templates: over-reliance on the template's parameters. It is tempting to rely on them, given time pressures in a busy office or ED. The problem is not unique to electronic records. Many hospitals and physician offices use forms in paper records for history and physical, progress notes, and oft-performed procedures.
Liability issues, before a court or a regulator, are myriad and thorny. Templates that are narrow in scope, say, limited to particular common diagnoses such as gastroenteritis, and that do not permit entry of data or impressions that can suggest alternative diagnoses, can lend credence to an argument that the correct diagnosis was not even considered. Further, such "rote" entries may appear to a jury to indicate a lack of attention to the details of the patient's treatment (if the records are "phoned in," the plaintiff would argue, then so was the treatment).