Notwithstanding the usual suspects that hinder electronic health record (EHR) implementation—initial costs, interoperability problems, training burdens, and altered physician-patient dynamics—there's also the risk of a pure system malfunction. In a malpractice suit after an admitted malfunction, a physician's actions will still be scrutinized.
Dr. PC had been the primary care physician to her 80-year-old patient for more than a decade, and in the years leading up to the event, assessed her with hypotension, hypothyroidism, adrenal insufficiency, kidney disease causing anemia, Addison's disease, bipolar affective disorder, and GERD. The patient was on a regimen of 14 different medications to manage her complicated medical conditions.
Some 7 weeks following the patient's last visit, electronic records showed prescriptions ordered for her by Dr. PC. Those separate electronic prescriptions showed a lower than usual prescription for the patient's thyroid medication and a new prescription for glipizide. Both electronic prescriptions correctly listed the patient's lengthy "other meds."
Two weeks later, the patient was admitted to the emergency room with an altered mental state. A head CT showed no pathology, but her fasting blood glucose was 22 (normal, 70-110).
The patient was diagnosed with acute encephalopathy stemming from the glipizide prescription. When the ED physician called Dr. PC about the glipizide, Dr. PC told her that the patient was not diabetic and that she did not prescribe glipizide. The ED physician then told Dr. PC that the patient had a prescription bottle for glipizide, with Dr. PC listed as the prescribing MD.
After a course of electrolytes and medication over 4 days at the hospital, the patient spent another 2 weeks at a nursing facility before going home in good condition.
Following the telephone call with the ED physician, Dr. PC reviewed her patient's chart and noted for the first time that she had electronically signed an order for glipizide. She immediately canceled the prescription and discussed the event with her partners, who told her they had noticed instances at around the same time of patients receiving medication prescribed for other patients.
Medscape Editor's Key Notes
• Even with correct user input, the information in a patient's record can be incorrect.
• Physicians checking boxes or signing off on medications should review changes to a patient's record to ensure accuracy.
• Even if the EHR itself creates an error, it carries the physician's electronic signature and therefore creates a liability risk.
Dr. PC's medical group contacted the EHR provider, which responded with a generic message several weeks after the incident, stating, "A few clients have recently reported that documents are being moved to another chart upon signing. We investigated this issue today … and we found this may happen to any type of document that is signed from the mailbox; i.e., the current document may be misfiled into the previous patient's chart right after being signed. Please watch for any misfiled documents in patients' charts." The letter recommended signing from an open chart as a work-around pending a software update.
When Dr. PC was sued by the patient for medical malpractice, her defense attorney filed a cross-complaint against the EHR provider. The EHR system then cross-complained against Dr. PC, alleging that the glipizide prescription was Dr. PC's own error.
Undercutting a defense that would have Dr. PC point to the EHR provider as the sole responsible party for the plaintiff's (fortunately) short-lived injuries was Dr. PC's own electronic sign-off on the glipizide prescription and the lack of documentation in the patient's record regarding contacting the EHR firm.
In its cross-complaint against Dr. PC, the company mentioned only briefly the EHR's patient-tracking features and instead focused heavily on its prescription-processing functions. The company alleged that Dr. PC entered the necessary information and "clicked the requisite tabs and icons" for the software to initiate her electronic signature for the prescription. Again focusing on the prescription component of the EHR system, the company alleged that there was "no bug or anomaly in the software, and that the software did not issue any prescriptions on its own accord."
The case resolved informally.
In the end, EHR systems are human systems. As such, physicians need to maintain all of the safeguards they would normally employ to guard against patient harm when using them.
This case comes from the "Case of the Month" column featured in the member newsletter published by the Cooperative of American Physicians, Inc. The article was originally titled "Physician Diligence Needed Even with EMR Systems."
© 2019 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.
Cite this: Gordon T. Ownby. Malpractice Case: You're Liable, Even if Your EHR Malfunctions - Medscape - Nov 04, 2019.