CAREFUL CONSIDERATION If you copy and paste information into the EHR or the software autopopulates certain fields, be sure to review the information for accuracy.

Electronic health records give caregivers quick and easy access to a patient's medical history, but the improper use of EHRs — whether it's intentionally falsifying records or making a simple typo — can lead to critical errors in patient care that could cause serious harm to patients and expose healthcare providers to medical liability.

The impact of improper EHR use on patient care can be devastating. Patients have been given incorrect doses, undergone unnecessary surgeries, been deprived of necessary care, and suffered long-term harm or death due to incorrect or missing information displayed on their EHRs. And often when this happens, patients or their families seek restitution by pursing legal action.

Common mistakes
Attempts by doctors to enter incorrect information to try to hide mistakes are well documented, but medical malpractice claims have also been the result of such minor and unintended data-entry mistakes as a typo or glitch in the software. Some of the most common EHR and documentation errors to watch for include:

• Data-entry mistakes, such as unintended typos or inadvertent deletions.
• Copy-and paste-errors, such as cutting and pasting from one EHR to another, or copying and pasting multiple times in the same EHR.
• Use of templates without subsequently verifying that the entered data is accurate. In other words, the software auto-populates information into the EHR and nobody confirms that it fairly describes the surgery.
• Data-entry errors by scribes who are not property trained to input data into the EHR.
• Failure of physician to carefully review the EHR.
• Errors caused by software updates.
• Errors caused by incompatibility between different EHR systems.
• Failures of the EHR software that results in loss of data that was not otherwise saved or backed up.

Intentional or negligent?
How the clinician entered the error into the record is especially important. The provider's intent separates an intentional tort from a negligence case. In an intentional tort malpractice case, the patient would need to show that the provider acted deliberately to cause the patient harm (for example, knowingly falsified records). Criminal charges are likely in these cases, and the damages in a civil suit for an intentional tort are typically higher compared to damages in a civil suit for negligence.

In general, most plaintiffs don't allege intentional conduct in a malpractice case. Instead, most malpractice cases must show that any negligence was a result of the provider's "willful and wanton" conduct, meaning the provider exhibited a reckless disregard for the safety of patients. For example, if a provider was under the influence of an illegal substance and then entered information into the EHR incorrectly, it could lead to a willful and wanton conduct malpractice claim. On the other hand, a claim that alleges a doctor made a simple copy-and-paste mistake is less likely to be deemed willful and wanton conduct.

It's usually more difficult to file a successful malpractice suit in cases where the plaintiff cannot prove the conduct was willful and wanton. However, keep in mind that these standards vary from state to state, so a simple typo could still put you at risk of a negligence lawsuit.

How to protect yourself
Electronic records give providers a quick and easy way to access a patient's history, prescriptions, lab results and other vital data in a way physical records never could. Nevertheless, clinicians must remain diligent in their review of entered data on a patient-by-patient basis.

Stress to staff members and physicians that they must observe care while entering information into the EHRs. They should double-check for accuracy data that is automatically filled into the EHR via auto-populating forms or templates. It is also recommended that you designate someone in your facility to routinely review updated EHRs for errors and to ensure that the software is working smoothly.

Also research the capabilities and reliability of your EHR system. Consult with your EHR vendor about how the system is installed, maintained and how the EHR should be properly used in the flow of patient care. In these discussions, ask about software updates, since they can cause minor glitches and inadvertently jumble up information, and if the EHR vendor will be accessible and responsive to address any issues. Another option is to check to see if a staff member at your facility can be trained in the software to troubleshoot any problems. Finally, you also want to know how the system works with other EHRs. For example, if a patient comes from a surgeon's office that uses a different EHR system, will the information transfer over seamlessly or will data need to be transferred manually?

Proper attention to detail and maintenance of the EHR is critical to adequate patient care. The best way to avoid the potential pitfalls of EHRs? Use the technology with caution and care. While the minor errors in electronic records can be a cause for concern, proper use of EHRs could potentially reduce the likelihood of medical malpractice claims due to resulting improvements in the quality of your patient care. OSM