Presented By: OHA Insurance Solutions, Inc.

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1 Presented By: OHA Insurance Solutions, Inc.

2 GOAL This course is designed to promote awareness of the importance of appropriate electronic medical record (EMR) and non-electronic charting to both professional patient care services and defending healthcare providers in professional negligence claims and suits. 2

3 OBJECTIVES Upon completion of this course, the participant will have gained a better understanding of: Purposes of medical record documentation. How the medical record is used in a professional negligence action. Electronic charting failures that can be detrimental to the defenses of professional negligence actions. Advantages and disadvantages of an EMR. Strategies that can be applied to reduce the risk of financial loss that might be associated with inadequate or improper EMR charting. 3

4 History of Electronic Medical Records (EMRs) 4

5 Documenting Patient Care Has Gone from Recording on a Hard Copy Record Format 5

6 to Documenting Patient Care Electronically 6

7 Electronic Medical Records (EMRs) Here to Stay No Turning Back 7

8 Electronic Medical Records (EMRs) The American Recovery and Reinvestment Act of 2009 set the wheels in motion by providing capital funding for investments in several areas, including healthcare. $19.5 Billion Stimulus Package for Electronic Medical Record (EMR) conversion in an effort to: Lower Healthcare Costs Reduce Medical Errors Improve Patient Care 8

9 Electronic Medical Records (EMRs) Medicare Reimbursement Rates to be cut if no EMR system in place beginning

10 Purpose of Paper & EMR Charting Reflects the care given to the patient. Demonstrates results of treatment. Assists in the planning and coordination of care for all disciplines. Demonstrates adherence to standards, rules and regulations. Provides documentation of patient care services for reimbursement purposes. 10

11 The Role of Electronic Medical Records During Litigation 11

12 Paper and EMR Charting Basic Standard of Care, the Duty Owed Considerations For a plaintiff to prevail in a professional negligence action they presumably must establish and prove four elements including: The healthcare provider owed a duty to the patient. The healthcare provider breached that duty. The patient suffered a resulting injury. The patient s injury was a proximate cause of the healthcare provider s breach. 12

13 Well Documented Charts May decrease the potential for a lawsuit to be filed. May increase the likelihood for filed cases to be dismissed early in the discovery process. May be the basis to contradict plaintiff allegations in losses. May lead to resolution decisions on the part of the defense teams, when problem charting issues are identified early in the litigation process. 13

14 Paper and EMR Charting Deficiencies Looked for by Plaintiff Attorneys Plaintiff Attorneys will look for anything in a paper record or EMR that may infer or establish professional negligence on the part of a healthcare provider. Omissions Contradictions and inconsistencies Time delays or unexplained time gaps Illegible, nonsensical or extraneous remarks Alterations, obliterations or the appearance of such Indications of feuding or finger pointing among professionals 14

15 Audit Trails May Be Discoverable Be aware that all interactions with the EMR create an audit trail and are time-tracked and discoverable. Litigation attorneys will request not only printed copies of the EMR but also the audit trail; sometimes referred to as metadata. 15

16 Audit Trails May Be Discoverable The audit trail/metadata includes: a summary of log on and log off times what was reviewed and for how long what changes or additions were made, and when these changes or additions were made 16

17 Example of Audit Trail Being Discoverable A primary care physician takes the position that - The nurse didn t tell me about the critical lab value. The audit trail will reveal who accessed the information, for how long, and when. For example, the audit trail identified that the nurse reviewed the lab result and reported it to the physician at

18 Example: How an EMR May Be Used Against a Healthcare Provider in a Professional Negligence Action An RN can be deposed and can expect the plaintiff attorney s line of questioning to be geared towards establishing areas of care provided to patients and whether communication with other healthcare practitioners was inconsistent with what the nurse documented in the EMR. 18

19 Example: How an EMR May Be Used in Depositions or in Trial Against a Healthcare Provider in a Professional Negligence Action Some of the fields in the EMR contained incorrect information, which may result in the plaintiff attorney asking these questions at deposition: Is the information in this record accurate or not? Do you bother looking at your records? If these EMR fields are incorrect, can we trust anything in this record? Do you deliver the same level of care as you do in record keeping? 19

20 Example: How an EMR May Be Used Against the Healthcare Provider in a Professional Negligence Claim Example of discrepancies between data: Scanned bar code entry for medication administration vs. nursing documentation regarding administration vs. metadata 20

21 In a professional negligence action, a healthcare provider s documentation is a reflection of the care provided. Documentation can protect the healthcare provider. Documentation can protect the hospital. Documentation can possibly deter a lawsuit. Poor documentation can be a hindrance to and negatively impact the outcome of a professional negligence action. 21

22 Electronic Medical Records Failures 22

23 Input Errors Just as a hard copy medical record lends itself to errors in legibility, misspellings, or other inputting, an EMR can also lead to documentation inaccuracies in the form of input errors. Always carefully review what is recorded in data fields. Never record care before it takes place. 23

24 Input Errors If erroneous information is entered into the EMR, it is easily perpetuated and disseminated. Leaving blanks when prompted with boxes and use of point and click technology signifies omissions. Notes being entered in the wrong patient record misleads any provider who subsequently consults the record. 24

25 Example: Input Error Provider reading the wrong patient chart and basing a treatment plan on incorrect information. Mr. Smith has a normal pap? Mrs. Jones has an elevated PSA? Patient s BP noted as 149/93 & & the fact that the entry was highlighted became suspect in litigation. 25

26 Benefits and Pitfalls of Drop Down Menus Templates with drop down menus facilitate data entry. Care providers often prefer drop down options because they take less time than typing in narrative text. However, drop down menu templates limit options and may not accurately reflect the patient s condition. Easy to click on incorrect option: Adult assessment for pediatric patient Misidentification of sex of patient 26

27 Importance of Narrative Don t forget that the EMR allows for narrative charting. If the patient s aspects of care cannot be documented to the EMR by drop downs or point and click, place it in the narrative. Drop down menus and point and click technology allow for efficient charting but do not encourage use of the section of the EMR for narrative charting. Providers are less likely to record pertinent observations. The EMR no longer paints a picture of the care provided. Without the narrative, there may be limited documentation regarding discussions with patient, family or other healthcare providers. 27

28 Log On/Log Offs Healthcare providers should log on / log off as themselves - Don t impersonate other care providers. Failure to log on / log off creates confusion in the record. Who really did care for patient? Allows plaintiff s counsel to cast doubt and uncertainty. Example - That s not my note. Failure to timely log off. Two Users / One Author. 28

29 Workarounds or Ignoring Alerts Alert Fatigue is a natural human reaction if EVERYTHING is an alert then NOTHING is an alert. 29

30 Workarounds or Ignoring Alerts Alert Fatigue creates a danger that care providers may ignore, disregard, override, or disable alerts, warnings, reminders, and embedded practice guidelines such as drug allergy alerts, drug interaction alerts, or test result tags such as L next to a low laboratory value. 30

31 Workarounds or Ignoring Alerts If it can be shown that following an alert or a guideline would have prevented an adverse patient event, the provider may be found liable for failing to follow it. Example Nurse ignores alert in Computerized Physician Order Entry System indicating potential drug interaction, resulting in adverse event. 31

32 Copy / Paste or Cloning Care providers may copy information from a prior note or assessment and carry it forward and paste it into a new note or assessment (known as copy/paste or cloning ), making changes where appropriate. This may result in irrelevant over-documentation. The patient may appear to have greater or less complex problems since the prior encounter. The narrative documentation of the patient s true daily progress and events may be unrecorded, thereby compromising the record of the patient s course. 32

33 Copy / Paste or Cloning Repeatedly recording past complaints or symptoms that are clinically irrelevant to a patient s current state of health can lead to medical errors. Example - Resident copied and pasted an admitting note on four consecutive hospital days. Orders were co-signed by Resident and Attending Physician. Patient was discharged without receiving the intended therapy of venous thromboembolism prophylaxis, despite each day s note stating this as part of the care plan. Error was discovered when patient required readmission. 33

34 Accessing Available Patient Information Care givers are responsible for information to which they have reasonable access. There is increasing access to e-health data from various sources such as the hospital s EMR system, hospital Web site, physician s office, clinic, pharmacy, consultants reports, lab results, radiology reports, community medication histories, etc. If the patient s injury results from a failure to access or make use of such available patient information, the hospital and care providers may be held liable. 34

35 EMRs Can Create a Perceived Lack of Follow-Up EMRs often have patient questionnaires that are used to interview the patient. These questionnaires often address and record in the medical record, issues that care givers do not pursue (depression, substance abuse, etc.). Lack of or incomplete follow-up can generate liability and provide a potential record for future legal action. 35

36 Advantages and Disadvantages of Electronic Medical Records 36

37 Advantages of Electronic Medical Records Are: Increases efficiency Data is readily available to others Improves quality and accuracy All information is available in one location Allows more patient care time Reduces the risk of misinterpretation 37

38 Advantages of Electronic Medical Records Are: Immediate availability of labs, EKGs, diagnostics Entries are dated, timed and authenticated Legible Reduces medication errors Less likely that records can be tampered with due to legal lock safeguards and access to an audit trail 38

39 Disadvantages of Electronic Medical Records Are: Lessens interaction and communication with patient and other healthcare providers Decreases privacy and confidentiality 39

40 Disadvantages of Electronic Medical Records Are: Blanks signify omissions Lack of Narrative / Point and Click / Fill in the Box Ability to log on under other users names Workarounds / Ignoring Alerts 40

41 Disadvantages of Electronic Medical Records Are: Cutting and Pasting / Cloning / Carrying Forward Information System downtime Audit trail is discoverable Metadata vs. Documented Entries What you see on the screen may not be in the same format as what is printed! 41

42 How to Minimize the Disadvantages of Electronic Medical Records 42

43 Don t Let Technology Depersonalize Medical and Nursing Relationships with the Patient It is very easy for the computer to become a barrier between the healthcare provider and the patient. 43

44 Don t Let Technology Depersonalize Medical and Nursing Relationships with the Patient When the healthcare provider is completing a computer template, it may divert attention from the patient, limit interactive conversation, and restrict creative thinking. Assure the computer is brought in to the patient s room in a location that doesn t force healthcare providers to have their back to the patient. 44

45 Surviving EMR System Downtime Be knowledgeable about the hospital s policy when the EMR system is down due to an unanticipated situation, such as a power failure. How to continue documenting patient care when there is no access to the EMR? How to revert to charting on paper? Once system is functioning, how is the information entered into the EMR - scanning the paper chart or manually entering the information? 45

46 What is Seen on the Screen May Not Be in the Same Format as What is Printed at a Later Date The printed EMR often bears no resemblance to the input screen. What is seen on the screen by a healthcare provider, when the care is provided to the patient, looks and is formatted differently than the printed document. 46

47 Conclusion We hope this course heightened awareness of the role that a healthcare provider s documentation plays in a professional negligence action and encourages more vigilant charting in an EMR. 47

48 Through this course the participant reviewed: Purposes of medical record documentation. How the medical record is used in a professional negligence action. What plaintiff attorneys look for in the medical record. Advantages and disadvantages of an electronic medical record. Electronic charting failures that can lead to indefensible documentation. How copying another care giver's record entry or his/her own prior entry and re-entering it as a current note can jeopardize patient safety and violate professional standards. How, if the information recorded by the care giver differs significantly from a computer audit trail, the content of the medical record and the care provided become suspect. Strategies that can be applied to reduce the risk of electronic medical record exposures. 48

49 Thank you for your participation! 49

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