Originally published December 2017
Electronic records are both a reality of modern clinical practice and a leading cause of stress for physicians.1 As they grow in sophistication, these systems offer new capabilities to support care and enhance safety. However, if not designed, implemented, or used appropriately, electronic medical records (EMRs) and electronic health records (EHRs) have the potential to negatively affect patient care and increase medical-legal risk, sometimes in unexpected ways.
The CMPA reviewed its medical-legal cases2 that closed between 2012 and 2016, and involved an issue with the EMR or EHR. The main issues identified in this review underline the importance of taking the following actions:
- Implementing electronic record systems appropriately, with functions installed and used optimally, and with supporting procedures in place.
- Verifying the accuracy of information when using an electronic record system.
- Ensuring that the use of these technologies does not interfere with the doctor-patient relationship.
How EMRs differ from EHRs
An electronic medical record (EMR) is an electronic version of the paper record maintained by physicians for their patients. It may be a simple office-based system or a shared record that connects healthcare professionals through a network. An electronic health record (EHR) is maintained by a hospital, regional health authority, or provincial or territorial government and typically includes a wider cross-section of information from a number of sources and is usually accessed by several authorized parties from a number of places of care.3
Implementing and optimizing electronic record systems
The diagnosis of a severe heart defect in a fetus is delayed when an obstetrician-gynecologist fails to review the results and follow-up recommendations of her patient’s 18-week morphology ultrasound. The delay occurred because the report was not flagged or filed in the expected section of her office's recently implemented EMR.
A hospital's department of medical imaging discovers that close to 100 reports were not uploaded into the computer system and not sent to ordering physicians during the period in which the EHR was being upgraded.
A family physician’s practice is audited after the medical regulatory authority (College) receives multiple complaints from patients. The complaints stem from the physician’s EMR not properly transmitting immunization records to the public health system.
In CMPA cases in which results go missing in a paper-based system, peer experts will often note that using an EMR can prevent such errors. While it is true that electronic records can facilitate test result management, delays in diagnosis can occur when systems are not properly implemented or optimized.
In this CMPA review, some cases involved missed or delayed diagnoses related to electronic record systems. In these cases, the systems made it difficult for users to identify when consultant reports or test results were not received or reviewed by the ordering physician. The system failures in these cases occurred because important functions in the EMR or EHR were not available, not installed, not working, or were overridden.
Another common issue is incomplete or illegible (i.e. scanned handwritten) entries in the record. This issue may be due to challenges entering information from the patient encounter or other sources into the record due to a lack of integration with different systems.
To minimize risk, consider the following features and functions when purchasing, implementing, or familiarizing yourself with a new system:
- The interface—Is information easy to enter and review? Can you find the latest entries and most recent results?
- Drop-down lists—Are they complete? Can drop-downs be customized to minimize the risk of error?
- System notifications—Can users create alerts and markers?
- Inter-operability—Can the EMR or EHR integrate with other electronic systems to ease information receipt and follow-up? If it is necessary to use a hybrid paper-electronic system for certain functions, what procedures can be developed to minimize error in information transfer?
- Audit trails—Does the record’s audit trail satisfy by-laws or regulations that stipulate audit trail functionality? Can you easily reproduce a copy of some or all of the record if a patient were to request it?
It is also important to plan for the transition from paper to electronic records. Consider how to prevent the loss of patient information or delays in the follow-up of test results during the implementation, upgrade, or transfer of a records system.
Verifying accuracy when using electronic records
A patient with rheumatoid arthritis is prescribed 7 times her weekly regular dose of methotrexate when her family physician accidentally uses his new EMR's pre-populated dosing frequency of "q daily" rather than adjusting it to reflect the weekly dosage schedule.
A patient develops C. difficile after receiving an inappropriate course of antibiotics for sinusitis. It is discovered that the family physician’s EMR transmitted the wrong prescription to the pharmacy under the patient’s name, resulting in the patient receiving a drug regimen intended for another patient.
These situations illustrate the risk of human errors when using the automated functions in an electronic record. Automation can make it easy for these types of errors to occur. For example, it can lead to prescription errors when drop-down lists contain expired prescriptions, prepopulated dosages give adult instead of pediatric amounts for medications, and default dosage frequencies are not suitable for specific patients. EMRs may also make it easier to perpetuate an error, such as an incorrect repeat prescription sent from an EMR to a pharmacy.
Several strategies may minimize risks from automation. Consider reviewing and editing all default data, and implementing a process or mechanism to review and approve orders sent through the EMR. Take care when using templates and auto-populate features, verifying that only visit-specific data is recorded and that all other default text is removed. Where possible, limit the automatic population of information. In a number of College cases, peer experts were critical when entries contained only default text or "cut and paste" notes that did not reflect what actually occurred during the encounter.
Ensuring that technology does not interfere with the doctor-patient relationship
In 12 of the reviewed cases, patients complained of physicians’ unprofessional manner or communication when they used a computer during an appointment. These patients viewed physicians as being distracted or lacking concern or empathy when they were interacting with the computer.
To make technology less intrusive to the patient encounter, consider reconfiguring your office layout so it is easier to make eye contact with patients while using a computer.
The bottom line
To enhance patient care and get the most out of electronic record systems, consider taking the following actions:
- Learn how to optimally use your electronic records system and its functions, and evaluate how it may support or affect your clinical care.
- Create procedures to optimize the functions and minimize risk.
- Consider how your use of an EMR and the physical layout of technology will affect interactions with patients.
- Friedberg M, Chen P, Van Busum K, Aunon F, Pham C, Caloyeras J, Mattke S, Pitchforth E, Ingram Quigley D, Brook R, Crosson J, Tutty M. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy . Santa Monica (CA): RAND Corporation; 2013 [cited 2017 Sept. 12]. Available from:https://www.rand.org/pubs/research_reports/RR439.html.
- Legal, regulatory authority (College), and hospital cases.
- Canadian Medical Protective Association [Internet]. Electronic Records Handbook. Ottawa (ON). CMPA; 2014 [cited 2017 Nov 11]. Available from: https://www.cmpa-acpm.ca/static-assets/pdf/advice-and-publications/handbooks/com_electronic_records_handbook-e.pdf.