EMR Pitfalls to Avoid

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Sara Marilynn Harvey
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1 EMR Pitfalls to Avoid esummit Safety Dr. Gordon Wallace, FRCPC Managing Director Safe Medical Care

2 Faculty / Presenter Disclosure Faculty: Gordon Wallace Employee of: CMPA (not-for-profit mutual defence association) Relationships with commercial interests: - Grants / Research Support: None - Speakers Bureau / Honoraria: None - Consulting Fees: None - Other: None Conflict of Interest - I have no financial or professional affiliation with any organization that can be perceived as a conflict of interest in the context of this presentation. Copyright - Not to be distributed without written permission of CMPA. No audio recording, video recording, or photography is allowed without CMPA's permission. Information is for general educational purposes only and is not intended to provide specific professional medical or legal advice or constitute a standard of care. Media Asset Copyright - All non-cmpa audiovisual files are used with permission and for educational purposes only. All rights belong to the original owner as per license agreements Thinkstock, YouTube and others as required.

3 How EMRs Improve Patient Care

4 The Good Fixes legibility of handwriting Date and time Relevant history and physical findings positive findings important negative findings Conclusions working, differential, and final diagnosis Plan of action investigations, consultations, treatment, follow-up rationale for the plan Information given to patient

5 Despite advantages, Medico-legal risks are emerging

6 What Will We Accomplish Today? Identify common pitfalls and medico-legal risks associated with EMR use Describe strategies to mitigate these risks

7 Cases and Lessons 1 Privacy breaches Lost records

8 I ve lost it!

9 Lost or stolen I ve lost it! Laptops Office computer systems CDs and DVDs Memory sticks, portable USB drives

10 Solution I ve lost it! Passwords not enough Electronic medical records = Think encryption Mobile devices = Think encryption

11 Cases and Lessons 2 Privacy breaches Viewing

12 Privacy breaches

13 Privacy breaches Time of care Time documented AUDIT TRAIL Which documents were viewed and for how long Any changes or additions Time spent viewing a lab test or diagnostic image

14 Case Improper Access of Information Privacy breaches A physician is censured for accessing an ex-spouse s personal health information Ex-husband snoops in ex-wife s EMR using resident s open sessions

15 Privacy and Confidentiality Privacy breaches Circle of care should have access Collective group of health professionals responsible for providing care to a patient Educate staff about privacy & confidentiality issues Training, training manual and confidentiality agreement for staff

16 Case Log Off! Privacy breaches A physician forgets to log-off when moving to another examination room Another patient ushered into the vacated room has full freedom to read the medical record of the previous patient

17 Password Security Privacy breaches

18 A Banking Case Our Only Non-Medical Case Privacy breaches Common law legal action Jones v. Tsige, 2012 Both bank employees Tsige has relationship with Jones ex Tsige snooped on Jones financial information in the bank records 174 times in 4 years! Intrusion Upon Seclusion Invasion of privacy = $10,000 damages!

19 Cases and Lessons 3 Interface design

20 Case Interface 35 yo male with abdominal pain and night sweats seen in clinic Abdomen ultrasound ordered At follow-up, doctor pulled up tests on EMR during visit:

21 Don t Forget To Scroll Down! Interface Doctor missed scrolling to the second paragraph of the impression: Impression : No cholelithiasis, no bile duct dilatation. Patient was falsely reassured Patient diagnosed with Stage 3B Hodgkins lymphoma Cluster of lymph nodes around renal hilum 6 months later Suggest CT/PET

22 Scrolling of Images AJR 2014;202:738 Axial Interface Coronal

23 Case A Discharge Summary Complaint Interface Patient A Sexual history from another patient s record open on the screen Patient B Mistakenly copies and pastes information into the wrong window

24 Cases and Lessons 4 Using automatic features

25 Templates / Check Boxes Auto Features

26 Default Text Auto Features Regulatory authority (College) determines a physician s record incorrectly filled by making wrong selection from a number of options on the electronic template for physical findings The College counsels the physician against using boiler plate default text

27 Use Automatic Features with Care Auto Features Doctor, your notes on your physical examination don t reflect really what happened. How can we believe anything you say?

28 Auto Features Paper charts If it wasn t charted it wasn t done With EMRs It s charted, but was it done?

29 Use Automatic Features with Care Auto features Free-text is protective

30 Cases and Lessons 5 Medication errors

31 Drop-down Menu Selection Med errors

32 Case Medication Order Entry Med errors A physician provides prescription for methotrexate but does not change the default q daily drop down to q weekly Acute renal failure requiring dialysis as a result of methotrexate toxicity

33 Medication Order Entry Med errors Double-check patient s name, identifiers, and date and time Select correctly from menus Drug names may look (or sound alike) Double-check starting, escalation, maintenance and tapering dosages

34 Cases and Lessons 6 Ignoring alerts

35 Proper Use of Decision Aids Alerts Clinical practice guidelines, clinical reminders Medication contraindications and interactions Differential diagnoses

36 Differential Diagnoses Alerts

37 Decision Aids Case Examples Alerts TB case Cavernous venous thrombosis

38 Decision Aids Alerts Alert fatigue desensitization System assumption dismissal = acknowledgement If you dismiss a particular suggestion: consider documenting your rationale and discussing this with the patient

39 Other medico-legal issues

40 What Is Your Best Defense? SAVED BY THE MEDICAL RECORD

41 Corrections and Additions The committee is deeply concerned that the medical record entered for Ms. X's Oct 8, 2010 visit was altered on February 3, 2011 following the complaint. Falsifying a medical record constitutes professional misconduct.

42 Corrections and Additions Clearly identified and dated addendum or late entry comment field Note date of notation being corrected Include reason for change (incorrect or omitted information, new information, patient correctedself, etc.) Enter the correct or missing information Identify author

43 You re Ignoring Me.

44 Conclusions 1 Privacy breaches Lost records 2 Privacy breaches Viewing 3 Interface design 4 Using automatic features 5 Medication errors 6 Ignoring alerts

45 Conclusion EMRs Offer real advantages But Ensure safe medical care Safety and medico-legal issues are emerging

46 What will you do differently next week?

48 Resources from CMPA Data sharing principles and electronic medical record/electronic health record agreements Electronic Records Handbook, CMPA, 2014

49 CMPA SAFE MEDICAL CARE CMPA GOOD PRACTICES GUIDE

Presented By: OHA Insurance Solutions, Inc.

Presented By: OHA Insurance Solutions, Inc. GOAL This course is designed to promote awareness of the importance of appropriate electronic medical record (EMR) and non-electronic charting to both professional