EMR Pitfalls to Avoid

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eSummit Safety

Dr. Gordon Wallace, FRCPC

Managing Director

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Faculty / Presenter Disclosure

Faculty: Gordon Wallace

Employee of: CMPA (not-for-profit mutual defence association)

Relationships with commercial interests:

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Grants / Research Support:

None________________________

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Speakers Bureau / Honoraria:

None________________________

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Consulting Fees:

None________________________

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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

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• Fixes legibility of handwriting

The Good

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

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Medico-legal risks are emerging

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What Will We Accomplish Today ?

• Identify common pitfalls and medico-legal risks

associated with EMR use

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Privacy breaches

Lost records

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Lost or stolen

• Laptops

• Office computer systems

• CDs and DVDs

• Memory sticks,

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Solution

• Passwords not enough

– Electronic medical records = Think encryption

– Mobile devices = Think encryption

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Privacy breaches

Viewing

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Time of care

Time documented

AUDIT TRAIL

Which documents were viewed and for how long

Any changes or additions

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Case

Improper Access of Information

• 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

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Privacy and Confidentiality

• Circle of care should have access

– Collective group of health professionals responsible

for providing care to a patient

Educate staff about privacy & confidentiality issues

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Case

Log Off!

• 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

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A Banking Case

Our Only Non-Medical Case

• 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!

Privacy breaches

Intrusion Upon Seclusion

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Interface design

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Case

• 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:

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Don’t Forget To Scroll Down!

Impression : No cholelithiasis, no bile duct

dilatation.

Cluster of lymph nodes around renal

hilum

Suggest CT/PET

Doctor missed scrolling to the second paragraph of the impression:

Patient diagnosed with Stage 3B Hodgkins lymphoma

6 months later

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Scrolling of Images

Interface

AJR 2014;202:738

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A Discharge Summary Complaint

Sexual history from

another patient’s

record open on the

screen

Patient A

Mistakenly copies

and pastes information

into the wrong window

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Using automatic features

4

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Default Text

• 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)

with Care

“Doctor, your notes on your

physical examination don’t reflect

really what happened.”

“How can we believe anything

you say?”

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If it wasn’t

charted it

wasn’t done

Paper charts

It’s charted,

but was it

done?

With EMRs

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Use Automatic Features with Care

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Cases and Lessons

Medication errors

5

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Case

Medication Order Entry

• 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

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Medication Order Entry

• 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

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Cases and Lessons

Ignoring alerts

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Proper Use of Decision Aids

• Clinical practice guidelines, clinical reminders

• Medication contraindications and interactions

• Differential diagnoses

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• TB case

• Cavernous venous thrombosis

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Alert fatigue → desensitization

System assumption

dismissal = acknowledgement

If you dismiss a particular suggestion:

consider documenting your rationale

and discussing this with the patient

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SAVED BY THE

MEDICAL RECORD

What Is Your Best Defense?

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“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

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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

corrected-self, etc.)

• Enter the correct or missing information

• Identify author

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Conclusions

Privacy breaches

Lost records

1 Privacy breaches

Viewing

2 Interface design

3 Medication

errors

5 Ignoring alerts

6 Using automatic

features

4

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• EMRs

– Offer real advantages

• But…

– Ensure safe medical care

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What will you do differently next week?

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Resources from CMPA

• Data sharing principles and electronic medical

record/electronic health record agreements

Electronic Records

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PRACTICES

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MEDICAL

CARE