How Have Electronic Medical Records Changed the Healthcare Industry?

If you’ve recently visited a doctor chances are they used Electronic Health Records (EHR) to document your visit. These records make it easier for doctors, pharmacies, and medical professionals to streamline their work, secure files, and reduce medical errors.

But it’s not all smooth sailing. Although some errors have decreased, medical professionals now encounter new and different types of errors since they switched to EHR. And if an EHR error leads to patient harm, it may even be considered medical malpractice.

How are Electronic Health Records Used in Healthcare?

Electronic Health Records (EHR) are digital files that medical professionals create, send, and maintain electronically.

Before Electronic Health Records

In the past, medical professionals maintained paper files for each patient and wrote paper orders and prescriptions by hand. They also communicated with other health entities such as pharmacies and insurance companies primarily via phone and fax. But this paper filing system had significant limitations.

These files were:

• Time-consuming to create and maintain
• Difficult to search through for specific information
• Sometimes incomplete
• Not readily accessible in an emergency
• Often handwritten and difficult to read
• Not standardized from one medical entity to another

As medical care has grown more complex, healthcare providers need a way to communicate quickly with specialists, insurance companies, pharmacies, and other health entities. EHR emerged as a partial solution to this problem.

EHR has existed since the 1970s. Early iterations were expensive and not widely adopted. Electronic records continued to evolve and develop with other technology, including personal computers and the Internet. In 2009, when President Obama passed the American Recovery and Reinvestment Act, EHR received a considerable push. This act incentivized medical professionals and companies who used EHR. Hospital groups, physicians, and insurance companies now consider EHR part of the standard of care.

What are the Benefits of Electronic Health Records?

Electronic health records have become indispensable in managing patients’ medical history and more.

Electronic health records can:

• Allow providers in different settings to communicate with each other and gain access to their patient’s records quickly.
• Automatically identify and alert doctors about medication allergies and drug interactions.
• Allow doctors to access years of their patient’s medical history quickly and easily.
• Reduce errors due to poor communication and sloppy handwriting.

Imagine a doctor needing to determine the best treatment for a patient’s new symptoms. With EHR, the doctor can easily search through years of that patient’s medical history right at their fingertips. Furthermore, the software may recommend a treatment or warn the doctor if their first choice of treatment is inappropriate. EHR can alert the doctor to any potential drug interactions or allergies and help determine if insurance covers the treatment. The doctor can then send the order or prescription electronically.

When used appropriately, EHR can help patients receive the most appropriate treatment. EHR is a powerful tool for quick, hassle-free, and accurate patient care.

What are the Different Types of Electronic Health Records?

Healthcare professionals use EHRs in a variety of settings. These include:

• Primary care doctors, nurse practitioners, and physician assistants
• Medical groups with multiple offices and specialties
• Hospitals and urgent care centers
• Health and dental insurance companies
• Pharmacies
• Laboratories

What EHR Errors Occur Most Often?

While EHRs can prevent certain types of errors, they also introduce new challenges.

Electronic Order and Prescription Errors

Doctors routinely send orders for procedures, tests, and prescriptions during treatment. Whether they order an x-ray or a course of antibiotics, they are more likely than ever to do so electronically. But, with this convenience comes the risk of EHR errors. A doctor may accidentally select the wrong test or drug from a drop-down menu, mistype instructions, or choose the wrong strength.

Wrong Patient Errors

One critical mistake that can render patient records incorrect is choosing the wrong patient. With an increasing number of patients sharing similar names, medical professionals must take extra care to verify multiple points of identification, such as date of birth or address.

Medical History Errors

EHR errors can occur when a patient’s medical history contains inaccuracies. In fact, according to the NIH, at least half of patients reported that EHRs may contain an error.

Some examples may include:

• Wrong Drug–A medical assistant chooses the wrong drug when documenting a patient’s allergies. The doctor refers to this list when prescribing a new medication and expects the EHR software to alert them to any contraindications. Because the medical history is inaccurate, the patient is now in danger of experiencing an allergic reaction. Similar errors can occur when the doctor documents a patient’s current medications. Many drugs interact with one another, so it’s critical to review this list for accuracy often.
• Wrong Diagnosis–The doctor may have given the patient an accurate diagnosis but documented it incorrectly in the EHR. This may not have immediate consequences, but if it goes uncorrected, it may cause problems down the line. For example, Insurance companies may deny necessary treatment until they resolve the problem. Additionally, a new doctor may refer to the patient’s medical history and provide different treatment than they would have if they had the correct information.

As a patient, you may have access to your medical history through patient portals provided by physicians, labs, and pharmacies. Given the large discrepancies that often exist in EHRs, it’s more important than ever to ensure that your healthcare records are correct and notify your doctor of any errors.

Errors Due to EHS Software

EHR software offers great convenience, but it also brings new problems including:

• Software Bugs and Glitches–These can corrupt files, delete records, or prevent the EHS from saving new information.
• User Experience Issues–Sometimes, EHR software works exactly how it should. However, because software engineers are not usually medical professionals, they may misunderstand how a doctor, nurse, or pharmacist uses the software. There’s a possibility that medical professionals use the software differently than intended. Similarly, the software may not allow the doctor to input necessary information in a helpful way. Doctors may have difficulties accessing vital information or alerts necessary for making the best medical decisions.
• Data Breaches–These may not necessarily lead to medical malpractice, but they do make medical records more vulnerable.

As each year passes, EHR companies continue to improve their software. EHR errors may never disappear completely, but increasingly sophisticated software can help reduce errors while providing all the advantages of electronic medical records.

How Do EHR Errors Differ from Other Medical Errors?

Paper and electronic health records can both lead to medical errors, but EHR errors can be unique. EHR errors sometimes occur because of the technology, not in spite of it.

• Too Much Information–When it comes to healthcare, more information is usually better. However, when doctors have access to seemingly unlimited information about their patient, they may overlook important details.
• Software Calling the Shots– EHR software might offer recommendations and warnings. For example, a physician’s software may recommend for or against certain medications based on a patient’s profile. The doctor may accept or decline these recommendations. The problem is that these recommendations do not always align with the best or most up-to-date practices.

How Do Electronic Health Records Affect Medical Malpractice Suits?

Electronic health records can make medical care easier, but they can also provide valuable evidence in a malpractice lawsuit.

In addition to containing large amounts of patient data, EHRs also record metadata showcasing who viewed or edited each file and when. This data can potentially help determine whether a medical provider was negligent. It can also assist investigators determine when and how an error occurred.

Ultimately, Electronic Health Records have enormous potential to improve patient safety and reduce overall risk. As technology continues to advance, EHRs can make medical care safer, faster, and more effective.

Contact WKW If You Have Experienced Malpractice Due to EHR Errors

If you have experienced an injury due to EHR errors or medical malpractice, you may be able to file a medical malpractice claim. Contact an experienced malpractice attorney at Wilson Kehoe Winingham today for a free consultation.

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