User and System Failures: The Problems with Electronic Health Records

Studies that have identified a connection between electronic health record (EHR) errors and medical malpractice claims divide the problems with EHR into two categories: system-related and user-related errors.

Flaws in the design of the EHR software are the major source of the system-related errors. For instance, many EHR templates lack sufficient space for documentation, precluding healthcare professionals from taking detailed notes during patient visits. Confusing displays and auto-population (a feature where the software automatically generates data) misinform medical professionals and leads to the transmission of inaccurate information. Furthermore, faulty technology may prevent medical professionals from accessing imperative information such as radiology studies or lab results.

System-related errors contribute to medical malpractice in several ways.  In one medical malpractice case, a physician did not have enough room to document all of the patient’s symptoms which led to the mismanagement of the patient’s condition and resulted in a cardiac event. In a different case, a physician could not access diagnostic imaging within the EHR which resulted in the delayed diagnosis of lung cancer.

The Doctor’s Company, a medical malpractice insurer, attributes issues with health care technology systems to the lack of input from physicians and other healthcare professionals in the initial development of EHR. The “subsequent workplace experience and concerns” [of medical professionals] have been largely ignored” with respect to problems they have encountered with EHR. Moreover, many vendors of EHR software are reluctant to address many of these design flaws. The Doctor’s Company argues that the problems associated with EHR likely would have been avoided had the Federal Government instituted standards for use and required beta testing to ensure the HIT was safe and user-friendly.

Among the several user-related issues contributing to medical malpractice, copy and paste errors by healthcare professionals have increased in the last ten years and the problem is only getting worse. Copying and pasting text—a common practice among healthcare professionals—from different sections of the health record and medical information from past and current visits “jeopardize[s] the integrity” of the medical record. The misuse of the copy and paste feature clutters the medical records with irrelevant, outdated, and potentially inaccurate information, making it difficult for physicians and nurses to sort through and make sense of the record.

Another significant problem associated with copying and pasting is the “‘death’ of the health record narrative.” With so much redundant information muddling health records, healthcare professionals have difficulty discerning a patient’s medical history, which is particularly problematic because the patient’s history is crucial for effective, clinical decision-making.  For example, a patient developed toxicity from the overuse of amiodarone because the patient’s medication history had been copied from a previous record which had failed to note that the patient had already been on this medication.

EHR errors continue to harm patients every day. The attorneys at Abramson, Brown & Dugan have vast experience handling medical malpractice claims. If you or someone you know is a victim of medical malpractice, please contact one of our attorneys today for a free consultation to discuss your legal rights.