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Avoiding EMR-Related Lawsuits In The ED

Posted on October 25, 2017 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

It’s hardly a secret that while EMRs may offer clinical benefits, they aren’t quite the patient safety or risk management tool one might hope they would be. Hospitals have much greater luck mining EMRs for clinical intelligence retroactively than they have using them to avoiding liability, in part because many aren’t designed to offer such protection.

But according to medical malpractice insurer CNA, there are steps hospitals can take to avoid EMR-related liability in the emergency department, in many cases if they simply avoid some key pitfalls which have caused problems for facilities in the past.

Avoiding copy and paste problems

As we all know, copying and pasting repetitive parts of a patient record from one note to another — such as the patient’s history — can save physicians lot of time. And if that’s all that gets copied, it’s seldom an issue.

However, when physicians rely too heavily on copy and paste functions, it can have a negative effect on patient care, in part by disseminating error-laden or outdated information, CNA has found. Overuse of copy-and-paste functions can also flood records with excess information and make it hard for subsequent providers to find what they need.

To avoid patient care errors associated with the use of copy and paste functions, CNA’s recommendations include the following:

  • Establish policies laying out how copy and paste functions should be used
  • Require clinicians to get ongoing education on proper use of these functions and patient safety risks associated with copy and paste misuse
  • Use a voice-activated dictation system for EMR data entry
  • Have the EMR highlight all copied information and/or prevent copying of high-sensitivity information such as the history of present illness
  • Audit EMRs to understand how providers use copy and paste, and responding when they seem to be abusing this function

Managing requests for EHR-based information

If your ED is facing a professional liability claim, you are likely to face requests for paper production of EMR archives. Part of your goal will be to limit how much EHR-based information is legally discoverable.

An important step in doing so is defining the legal medical record (LMR), which includes information on the provision of clinical care which would reasonably be expected upon request during discovery.

However, producing paper copies of EMR-based information differs from producing records originally created on paper, and hospital emergency departments might face additional liability issues if they haven’t prepared for this adequately. To do so, steps they can take include:

  • Developing policies and procedures for responding to requests for copies of the EMR and audit trails
  • Offering ongoing education for medical staff and employees on best practices for EMR documentation
  • Disclosing the EMR electronically in read-only mode rather than as a paper document

Eventually, of course, hospitals will want to do more than patch together defenses against problems that can occur when using a typical EMR design. Ultimately hospitals will want to make EMRs easy to use and supportive of clinical goals without being too intrusive. I know, most of us feel like we’ll grow old and gray waiting for this to happen, but we mustn’t let it fall off the radar.

In the meantime, the strategies CNA outlines could help your ED avoid medical malpractice litigation and protect patients from needless harm. It may be a transitional strategy but it’s better than nothing.

E-Patient Update: Before You Call Me A “Frequent Flier,” Check Your EMR

Posted on April 28, 2017 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

While there’s some debate about what constitutes an emergency, there’s no doubt I’ve had a bunch of ambiguous, potentially symptoms lately that needed to be addressed promptly. Unfortunately, that’s exposed me to providers brainwashed to believe that anyone who comes to the emergency department regularly is a problem.

Not only is that irritating, and sometimes intimidating, it’s easy to fix. If medical providers were to just dig a bit further into my existing records – or ideally, do a sophisticated analysis of my health history – they’d understand my behavior, and perhaps even provide more effective care.

If they looked at the context their big ‘ol EMR could provide, they wouldn’t waste time wondering whether I’m overreacting or wasting their time.

As I see it, slapping the “frequent flier” label on patients is particularly inappropriate when they have enough data on hand to know better. (Actually, the American College of Emergency Physicians notes that a very small number of frequent ED visitors are actually homeless, drug seekers or mentally ill, all of which is in play when you show up a bit often. But that’s a topic for another time.)

Taking no chances

The truth is, I’ve only been hitting the ED of late because I’ve been responding to issues that are truly concerning, or doing what my primary doctor or HMO nurse line suggests.

For example, my primary care doctor routed me straight to the local emergency department for a Doppler when my calves swelled abruptly, as I had a DVT episode and subsequent pulmonary embolism just six months ago.

More recently, when I had a sudden right-sided facial droop, I wasn’t going to wait around and see if it was caused by a stroke. It turns out that I probably had an atypical onset of Bell’s Palsy, but there was no way I was going to try and sort that out on my own.

And given that I have a very strong history of family members dropping dead of MI, I wasn’t going to fool around when I felt breathless, my heart was racing and I my chest ached. Panic attack, you’re thinking? No, as it turned out that like my mother, I had aFib. Once again, I don’t have a lab or imaging equipment in my apartment – and my PCP doesn’t either – so I think I did the right thing.

The truth is, in each case I’d probably have been OK, but I erred on the side of caution. You know what? I don’t want to die needlessly or sustain major injuries to prove I’m no wimp.

The whole picture

Nonetheless, having been to the ED pretty regularly of late, I still encounter clinicians that wonder if I’m a malingerer, an attention seeker or a hypochondriac. I pick up just a hint of condescension, a sense of being delicately patronized from both clinicians and staffer who think I’m nuts. It’s subtle, but I know it’s there.

Now, if these folks kept up with their industry, they might have read the following, from Health Affairs. The article in question notes that “the overwhelming majority of frequent [ED} users have only episodic periods of high ED use, instead of consistent use over multiple years.” Yup, that’s me.

If they weren’t so prone to judging me and my choices – OK, not everyone but certainly some – it might occur to them to leverage my data. Hey, if I’m being screened but in no deep distress, why not ask what my wearable or health app data has told me of late? More importantly, why haven’t the IT folks at this otherwise excellent hospital equipped providers with even basic filters the ED treatment team can use to spot larger patterns? (Yeah, bringing big data analytics into today’s mix might be a stretch, but still, where are they?)

Don’t get me wrong. I understand that it’s hard to break long-established patterns, change attitudes and integrate any form of analytics into the extremely complex ED workflow. But as I see it, there’s no excuse to just ignore these problems. Soon, the day will come when on-the-spot analytics is the minimum professional requirement for treating ED patients, so confront the problem now.

Oh, and by the way, treat me with more respect, OK?

Should Hospitals Track ED “Frequent Fliers” In Their EMR?

Posted on October 28, 2016 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Particularly as value-based reimbursement falls into place, hospitals have good reasons to track emergency department utilization across populations. As with readmissions, ED visit rates and diagnoses can tell you something valuable about patients’ conditions and the extent to which they are managing those conditions, as well.

However, tracking individual ED use, especially by behavioral health patients, may result in less-desirable consequences. In fact, according to a viewpoint article published recently in JAMA, adding icons or symbols to the records of patients who are considered to be “superusers” or “frequent fliers” can stigmatize patients and create bias against them.

“A pejorative branding, ‘frequent flyers’ are often assumed to be problem patients. In psychiatric settings, these patients are sometimes said to be ‘borderlines,’ ‘drug seekers,’ ‘malingerers,’ or ‘treatment resistant,’ according to authors Michelle Joy, MD, Timothy Clement, MPH and Dominic Sisti, PhD.

The researchers note that at least one EMR offers the capacity to insert an airplane icon beside the patient’s name, and not only that, to display the icon in different colors depending on where the patient falls among the high using population. But they consider this to be ethically and clinically inappropriate.

For one thing, they say, uses such an icon ‘encourages the use of disrespectful and stigmatizing terminology.’ What’s more, the use of such labels may change the clinician’s initial interactions with the patient in a way that affects their judgment negatively, and may subject the patient to the risk of a poor outcome from their care.

Not only that, they point out, while it might be useful to know that a patient presents in the ED frequently, determining why this happens can only take place if the clinician does a deeper dive into their utilization history. And slapping a high utilization icon the patient record actually discourages such in-depth examination, they contend.

On top of all that, if the patient is assumed to be visiting the ED frequently for largely psychiatric reasons, “diagnostic overshadowing” may occur, to the patient’s detriment. For example, they note, if a patient has a co-occurring mental illness in a condition such as cardiovascular disease, the patient is less likely to receive adequate medical care than patients without a medical condition, as the psych diagnosis overshadows their medical problems.

To avoid creating signifiers like the icon, which may build in the makers’ implicit biases, EMRs and behavioral health apps should be filled and tested in collaboration with patients, consumers, ethicists and other parties sensitive to the broader ramifications of using such language and iconography, the authors suggest.

In the meantime, readers of this publication might want to stop and think if there are any other ways in which the health IT systems they design and use reflect other unhelpful biases. While placing a frequent flyer icon beside a patient’s name seem like a particularly egregious instance — or does to me anyway – there may be subtler ways in which your HIT systems foster negative or inappropriate assumptions. And it’s good to dig those out and examine them. After all, nobody wins when patients fail to get the care they need.