Most healthcare records today are created through electronic means rather than paper records. The HITECH Act in 2009 provided financial incentives for hospitals and physician practices to implement technologies that created electronic health records for patients. While electronic records can increase the speed of creating records and make it easier to share information, they pose challenges. They may introduce new causes of action for medical malpractice lawsuits.

Electronic health records are an integral part of patient care. Likewise, they can have a significant impact on medical malpractice claims. Understanding how these medical records can be used in your medical malpractice case and the benefits and challenges of electronic health records can be pivotal to your case.

What Is an Electronic Health Record?

An electronic health record (EHR) collects a patient’s health information. EHRs may include electronic medical records (EMRs), like a patient’s paper medical chart, but in electronic form. An EMR contains valuable information about a patient’s medical history and treatment, including diagnoses and dates.

EHRs contain the records of multiple medical offices. An EHR may contain information such as:

Demographics
Family history
Clinical history
Immunization dates
Allergies
Diagnoses
Current and past medications
Treatment plans
Lab results
Radiology images

Medical providers typically use the internet or internal databases to access a patient’s EHR. Various healthcare providers may be able to access this information.

How Healthcare Providers Create Electronic Health Records

Medical professionals collect information about patients as they provide care. They can do this by asking questions, having patients fill out written forms, or notating their findings after exams. Some doctors use voice recordings, too. This information is ultimately uploaded to a digital form to store on a computer or digital network.

Many medical providers outsource the creation of electronic medical records to third parties, such as medical transcriptionists. These third parties create digital records and store them for medical practices.

The Role of Electronic Health Records in Medical Malpractice Cases

EHRs and EMRs can be valuable for a medical malpractice case. They contain many details about a patient and their interactions with medical staff. They can help identify the factors that contributed to an adverse event. In some situations, they can help establish a breach of the standard of care and liability.

Medical malpractice lawyers can more easily organize, understand, and find relevant information about a client’s case with EHRs because they are searchable. An attorney can look for certain terms or isolate specific timeframes or procedures to find information related to the case. This also helps medical experts evaluating the claim find the information they need efficiently.

EHRs also contain metadata showing when and who accessed the medical record. These medical records can also show what information the person accessing the information viewed, added, or deleted, which may help pinpoint when a medical error was made.

Do Electronic Health Records Lead to More Occurrences of Medical Malpractice?

While electronic health records can help share information among providers and improve patient safety, they can also lead to errors. One study reviewed 248 submitted medical closed malpractice claims that were health IT-related. Of these, 31% involved medication errors, 31% involved a complication of treatment, and 28% involved diagnostic errors. More than 80% of cases involved moderate or severe harm to patients, with some resulting in fatal consequences.

One consistent problem was that many errors occurred in ambulatory care settings, potentially suggesting the necessary information needed to be more readily available in emergencies. Because EHRs are relatively new and the laws surrounding them continue to evolve, the impact of EHR on malpractice is only partially known. An experienced medical malpractice attorney can review your case to determine if EHRs contributed to your adverse health outcome.

Benefits of Electronic Health Records

Electronic health records offer numerous benefits to patients, healthcare providers, and third parties, including:

Greater Accessibility

EHRs allow multiple doctors and other healthcare providers to access information when needed to provide patient care. This can improve the patient’s continuum of health care because the medical professionals who need access to the information have it and do not have to wait for lengthy medical records request procedures.

Potential to Avoid Mistakes Caused by Handwriting

Doctors are notorious for their poor penmanship. Digital records may increase safe patient care by eliminating errors caused by handwritten medical notes and prescriptions.

Enhanced Speed of Creating and Accessing Records

While delays in transcription may still occur, EHRs can reduce them by allowing healthcare professionals and third parties to add to healthcare records more quickly. Additionally, healthcare providers can access longitudinal information about a patient’s medical history, allowing the provider to have years of a patient’s information at their fingertips.

Enhanced Communication Among Healthcare Professionals

EHRs allow providers in different healthcare settings to access this information. They do not have to work at the same practice to have the same patient information. For example, a recently hospitalized patient may have this information shared with their primary care provider, who can follow up with outpatient care. This can enhance provider communication and ensure all the information is received.

Automatic Alerts

Some electronic healthcare systems automatically alert practitioners of medication allergies or potentially harmful drug interactions. These alerts can prevent a doctor from making a harmful medication error, improving healthcare safety.

Challenges of Electronic Health Records

While electronic health records can provide access to health records among various healthcare community members, they can also introduce specific challenges. According to Harvard research, the primary factors accounting for half of the study’s EHR malpractice cases were user error, incorrect information in the medical record, pre-populating errors, conversion issues, and system issues.

We discuss these and other challenges of electronic health records below:

User Error

User-related issues stem from mistakes medical providers make, such as:

Ordering a medication despite receiving an alert regarding an allergic reaction
Forgetting passwords and not being able to access critical medical information
Not documenting important information, such as medications the patient is taking, medication side effects, or symptoms.

These issues are sometimes due to a need for more training or education related to medical record systems.

Incorrect Information Error

Healthcare providers are responsible for accurately recording patient information, including family history, clinical history, medications, diagnoses, and medications. Incorrect information errors occur when healthcare providers input incorrect patient information. They may accidentally have another patient’s record open and input that information into the other patient’s record. They could select the wrong item from a drop-down menu.

A common cause of incorrect information being included in a medical record is the copy-and-paste function. Copy and paste errors occur when one healthcare professional records incorrect information in the medical record and subsequent providers copy and paste the same information. Healthcare providers may rely on the more recent information to the patient’s detriment.

When healthcare professionals do not accurately input information in EHRs, medication errors, diagnostic errors, and delayed treatments may harm patient safety.

Pre-Populating Error

Medical record systems sometimes auto-populate fields to save transcriptionists time. However, this information is not always accurate. If this information auto-populates about a patient’s history, physical examination, or procedure and the medical provider does not manually review and adjust it, the patient’s record could include incorrect or outdated clinical information.

Conversion Issue

EHRs are only partially portable. Healthcare providers may use different systems. These systems may only sometimes be compatible, leading to potential issues. Somebody may fail to insert Information in the appropriate location, or the information may go missing altogether.

Medical record errors can also be introduced when converting medical records into paper or voice recordings.

System Issue

System-related issues involve issues with the design or technology of the EHR system. Healthcare professionals may be unable to access vital medical information at a critical time. The Harvard study noted several critical system issues that resulted in significant patient harm, including:

A primary care provider could not access radiology studies during the patient visit and did not review the results once they were in, so the patient suffered a delayed diagnosis of lung cancer.
The medical records system did not provide a large enough complaint field, which shortened the description of the patient’s system, resulting in the patient receiving a mismanaged workup and later cardiac event.
The doctor was unable to access the emergency department triage note, so the patient was misdiagnosed and died.

Many EHR malpractice cases arise out of problems in emergencies when healthcare providers cannot access critical medical records, and they need to make informed treatment decisions. They may be unable to access information related to emergency department visits, hospital admissions, specialist reports, lab results, or acute care notes.

According to Harvard research, EHR-related errors that occur in emergency care settings result in more significant patient harm at 57% of reported claims than in inpatient settings, which are reported in 45% of cases or 39% of ambulatory settings.

Missing Information

Healthcare data issues can also arise when medical professionals fail to input all pertinent information in the patient’s medical record. If the information is not recorded, the provider may not remember it later on, or another medical provider may not be aware of it. These omissions can result in serious issues in medical care.

Interpretation Error

Busy medical practices may receive hundreds of lab, X-ray, and consultation reports daily. Medical providers should review these images before incorporating them into the patient’s electronic health record. Misinterpreting test or imaging results can harm patient care.

Medication Error

EHRs can contribute to medication errors. Medication-related errors can happen when a transcriber types the wrong name, a provider fails to ask about other medications the patient takes, or the health record does not contain information about previous adverse reactions.

Security

Another concern regarding electronic health records is that they may not be secure. Healthcare professionals or transcriptionists may take patient charts home to convert information to an electronic record. Medical providers can have their devices stolen or their systems hacked.

Common EHR Malpractice Cases

EHRs can potentially lead to various types of medical errors that give rise to medical malpractice claims, including:

Electronic order errors – A doctor may order the wrong type of test or procedure from a drop-down menu, which could subject the patient to harmful tests or cause them not to have the kind of test that could alert the provider to their medical condition.
Medication errors – Healthcare providers may select the wrong medication, strength, or form of administration from a drop-down menu. If a medication reconciliation is incorrect, the doctor could prescribe the patient a drug that has a dangerous interaction.
Wrong patient errors – The medical provider may select the wrong patient when inputting information, thereby introducing medical errors into two patient’s charts.
Diagnostic errors – Medical professionals can make mistakes in diagnosing a patient when the EHR contains missing or inaccurate information. A new doctor may defer to the patient’s previous medical information in their EHR and provide different treatment than they otherwise would have if they had the correct information. This can perpetuate diagnostic errors.

Contact Our Experienced Legal Team for Help with Your EHR Malpractice Case

If a medical provider’s negligence harmed you, our experienced medical malpractice attorneys can help. We offer a free case review in which we can evaluate your case, advise you of your legal rights, and discuss options for pursuing compensation. Contact us online or call us at (518) 720-6188 to get started.