Medical malpractice liability in the age of electronic health records

Development and validation of an instrument to evaluate the perspective of using the electronic health record in a hospital setting

BACKGROUND

Evaluating healthcare information systems, such as the Electronic Health Records (EHR), is both challenging and essential, especially in resource-limited countries. This study aims to psychometrically develop and validate an instrument (questionnaire) to assess the factors influencing the successful adoption of the EHR system by healthcare professionals in Moroccan university hospitals.

METHODS

The questionnaire validation process occurred in two main stages. Initially, data collected from a pilot sample of 164 participants underwent analysis using exploratory factor analysis (EFA) to evaluate the validity and reliability of the retained factor structure. Subsequently, the validity of the overall measurement model was confirmed using confirmatory factor analysis (CFA) in a sample of 368 healthcare professionals.

RESULTS

The structure of the modified HOT-fit model, comprising seven constructs (System Quality, Information Quality, Information technology Service Quality, User Satisfaction, Organization, Environment, and Clinical Performance), was confirmed through confirmatory factor analysis. Absolute, incremental, and parsimonious fit indices all indicated an appropriate level of acceptability, affirming the robustness of the measurement model. Additionally, the instrument demonstrated adequate reliability and convergent validity, with composite reliability values ranging from 0.75 to 0.89 and average variance extracted (AVE) values ranging from 0.51 to 0.63. Furthermore, the square roots of AVE values exceeded the correlations between different pairs of constructs, and the heterotrait-monotrait ratio of correlations (HTMT) was below 0.85, confirming suitable discriminant validity.

CONCLUSIONS

The resulting instrument, due to its rigorous development and validation process, can serve as a reliable and valid tool for assessing the success of information technologies in similar contexts.

Pharmacy students' perspectives on the initial implementation of a teaching electronic medical record: results from a mixed-methods assessment

BACKGROUND

Electronic medical records (EMRs) have been used for nearly three decades. Pharmacists use EMRs on a daily basis, but EMRs have only recently been incorporated into pharmacy education. Some pharmacy programs have implemented teaching electronic medical records (tEMRs), but best practices for incorporating tEMRs into pharmacy education remain unknown. The objectives of this study were to 1) assess pharmacy students' views and experiences with a tEMR; and 2) identify current learning activities and future priorities for tEMR use in pharmacy education.

METHODS

We used a mixed-methods approach, including three, two-hour student focus groups and a 42-item web-based survey to examine student perspectives of the tEMR. All first, second, and third year professional pharmacy students were eligible to participate in the survey and a focus group. Web-based survey items were measured on a 7-point Likert scale, and quantitative analyses included descriptive statistics. Two researchers independently coded transcripts using both deductive and inductive approaches to identify emergent themes. These analysts met and resolved any coding discrepancies via consensus.

RESULTS

Focus groups were conducted with 22 total students, with 6-8 students represented from each year of pharmacy training. The survey was completed by 156 students: 47 first year, 55 second year, and 54 third year. Overall, 48.7% of survey respondents altogether agreed or strongly agreed that using the tEMR enhanced their learning in pharmacy classes and laboratories. Qualitative data were organized into four major themes regarding tEMR adoption: current priorities for use within the pharmacy curriculum; tEMR benefits; tEMR barriers; and future priorities for tEMR use to prepare students for pharmacy practice.

CONCLUSIONS

This study reveals pharmacy students' perspectives and attitudes towards using a tEMR, the types of classroom activities that incorporate the tEMR, and students' future suggestions to enhance the design or application of the tEMR for their learning. Our research findings may aid other pharmacy programs and promote more effective use of tEMRs in pharmacy education. In the long-term, this study may strengthen pharmacy education on EMRs and thus increase the efficacy and safety of pharmacists' EMR use for patients' medication management.

[Legitimate resistance without technophobia: Analysis of electronic medical records impacts on the medical profession]

The objective of this short narrative literature review is to highlight the different difficulties encountered by medical doctor in the daily use of EMR. We show that these are not simple transitional phenomena related to a "resistance to change", but rather the fact of a deeper and unfinished transformation. Beyond the "perception of misfit with work processes" or the threat of a loss of autonomy, we propose to analyze this so-called "resistance" in relation to the formalization of medical work induced by EMR. Our question concerns the compatibility of the multiple objectives of EMR, the potential influence of computerization on the steps of entering and consulting medical information, the impact on the clinical reasoning, the reality of assistance to medical "performance". The question is not so much what EMRs do less well than the paper record, but to provide insights into how tomorrow's EMRs will do better than today's.

Cross-Cover Documentation: Multicenter Development of Assessment Tool for Quality Improvement

Construct: We aimed to develop an assessment tool to measure the quality of electronic health record inpatient documentation of cross-cover events. Background: Cross-cover events occur in hospitalized patients when the primary team is absent. Documentation is critical for safe transitions of care. The quality of documentation for cross-cover events remains unknown, and no standardized tool exists for assessment. Approach: We created an assessment tool for cross-cover note quality with content validation based on input from 15 experts. We measured interrater reliability of the tool and scored cross-cover note quality for hospitalized patients with overnight rapid response team activation on internal medicine services at 2 academic hospitals for 1 year. Patients with a code blue or a clinically insignificant event were excluded. The presence of a note, writer identity (resident or faculty), time from rapid response to documentation, note content (subjective and objective information, diagnosis, and plan), and patient outcomes were compared. Results: The instrument included 8 items to determine quality of cross-cover documentation: reason for physician notification, note written within 6 hours, subjective and objective patient information, diagnosis, treatment, level of care, and whether the attending physician was notified. The mean Cohen's kappa coefficient demonstrated good interrater agreement at 0.76. The instrument was scored in 222 patients with cross-cover notes. Notes documented by faculty scored higher in quality than residents (89% vs. 74% of 8 items present, p < .001). Cross-cover notes often lacked subjective information, diagnosis, and notification of attending, which was present in 60%, 62%, and 7% of notes, respectively. Conclusions: This study presents reliability evidence for an 8-item assessment tool to measure quality of documentation of cross-cover events and indicates improvement is needed for cross-cover education and safe transitions of care in acutely decompensating medical patients.

Completeness of Electronic Dental Records in a Student Clinic: Retrospective Analysis

BACKGROUND

A well-designed, adequately documented, and properly maintained patient record is an important tool for quality assurance and care continuity. Good clinical documentation skills are supposed to be a fundamental part of dental student training.

OBJECTIVE

The goal of this study was to assess the completeness of electronic patient records in a student clinic.

METHODS

Completeness of patient records was assessed using comparative review of validated cases of alveolar osteitis treated between August 2011 and May 2017 in a student clinic at Columbia University College of Dental Medicine, New York, USA. Based on a literature review, population-based prevalence of nine most frequently mentioned symptoms, signs, and treatment procedures of alveolar osteitis was identified. Completeness of alveolar osteitis records was assessed by comparison of population-based prevalence and frequency of corresponding items in the student documentation. To obtain all alveolar osteitis cases, we ran a query on the electronic dental record, which included all cases with diagnostic code Z1820 or any variation of the phrases "dry socket" and "alveolar osteitis" in the notes. The resulting records were manually reviewed to definitively confirm alveolar osteitis and to extract all index items.

RESULTS

Overall, 296 definitive cases of alveolar osteitis were identified. Only 22% (64/296) of cases contained a diagnostic code. Comparison of the frequency of the nine index categories in the validated alveolar osteitis cases between the student clinic and the population showed the following results: severe pain: 94% (279/296) vs 100% (430/430); bare bone/missing blood clot: 27% (80/296) vs 74% (35/47) to 100% (329/329); malodor: 7% (22/296) vs 33%-50% (18/54); radiating pain to the ear: 8% (24/296) vs 56% (30/54); lymphadenopathy: 1% (3/296) vs 9% (5/54); inflammation: 14% (42/296) vs 50% (27/54); debris: 12% (36/296) vs 87% (47/54); alveolar osteitis site noted: 96% (283/296) vs 100% (430/430; accepted documentation requirement); and anesthesia during debridement: 77% (20/24) vs 100% (430/430; standard of anesthetization prior to debridement).

CONCLUSIONS

There was a significant discrepancy between the index category frequency in alveolar osteitis cases documented by dental students and in the population (reported in peer-reviewed literature). More attention to clinical documentation skills is warranted in dental student training.

Clinical Audit on the Practice of Documentation at Preanesthetic Evaluation in a Specialized University Hospital

Background:

Performing preanesthetic evaluation, documenting, and keeping readily accessible record are responsibilities of anesthetists. Documentation can improve overall patient outcome. It also has an irreplaceable role in medico-legal aspects. Documentation is one of the challenges of providing quality care.

Aim:

The aim of this study was to evaluate the quality of documentation practice during preanesthetic visits.

Materials and Methods:

This clinical audit was conducted in the University of Gondar Hospital. Predefined 22 practice quality indicators were prepared according to modified global quality index.

Statistical Analysis:

Descriptive statistics was performed using SPSS version 20.

Results:

A total of 122 preanesthetic evaluation tools (PAETs) were reviewed. None of PAETs found fully completed according to the indicators. Trends differ between elective and emergency conditions. Indicators with high completion rate (>90%) were signed a consent, medical history, history of medication, allergy, anesthesia and surgery, cardiopulmonary examination, airway examination, preoperative diagnosis, and planned procedure. Anesthetic plan, vital signs, a name, per-oral status, premedication, and age were found with below average (<50%) completion rate.

Conclusions:

Documentation practice during the preanesthetic visit was below the standard. Unclear instructions should be replaced with standardized contents. Providing regular trainings on clinical documentation for students and staffs, and introducing modern electronic-based documentation system and preanesthetic clinics may improve the practice.

Exploring Perceptions of Health Care Providers' Use of Electronic Advance Directive Forms in Electronic Health Records

The current study explored the perceptions of health care providers' use of electronic advance directive (AD) forms in the electronic health record (EHR). The Technology Acceptance Model (TAM) was used to guide the study. Of 165 surveys distributed, 151 participants (92%) responded. A moderately strong positive correlation was noted between perceived usefulness and actual system usage (r = 0.70, p < 0.0001). Perceived ease of use and actual system usage also had a moderately strong positive correlation (r = 0.70, p < 0.0001). In contrast, the strength of the relationship between behavioral intention to use and actual system usage was more modest (r = 0.22, p < 0.004). There was a statistically significant difference in actual system usage of electronic ADs across six departments (χ²[5] = 79.325, p < 0.001). The relationships among primary TAM constructs found in this research are largely consistent with previous TAM studies, with the exception of behavioral intention to use, which is slightly lower. These data suggest that health care providers' perceptions have great influence on the use of electronic ADs. [Journal of Gerontological Nursing, 45(1), 17-21.].

Descriptive Analysis of State and Federal Spine Surgery Malpractice Litigation in the United States

STUDY DESIGN

A retrospective review.

OBJECTIVE

This study aimed to determine the factors associated with malpractice litigation in cases involving spine surgery in the United States.

SUMMARY OF BACKGROUND DATA

Medical malpractice is of substantial interest to the medical community due to concerns of increased health care costs and medical decision-making for the sole purpose of reducing legal liability.

METHODS

The Westlaw online legal database (Thomson Reuters, New York, NY) was searched for verdict and settlement reports pertaining to spine surgery from 2010 to 2015. Data were collected regarding type of procedure, patient age and gender, defendant specialty, outcome, award, alleged cause of malpractice, and factors involved in the plaintiff's decision to file. Initial search queried 187 cases, after which exclusion criteria were applied to eliminate duplicates and cases unrelated to spine surgery, yielding a total of 98 cases for analysis.

RESULTS

The verdict was in favor of the defendant in 62 cases (63.3%). Neurosurgeons and orthopedic surgeons were the most common defendants in 29 (17.3%) and 40 (23.8%) of the cases, respectively. A perceived lack of informed consent was noted as a factor in 24 (24.4%) of the cases. A failure to diagnose or a failure to treat was noted in 31 (31.6%) and 32 (32.7%) cases, respectively. Median payments for plaintiff verdicts were nearly double those of settlements ($2,525,000 vs. $1,300,000). A greater incidence of plaintiff verdicts was noted in cases in which a failure to treat (P < 0.05) was cited, a patient death occurred (P < 0.05), or an emergent surgery had been performed (P < 0.01).

CONCLUSION

Overall, physicians were not found liable in the majority of spine surgery malpractice cases queried.

LEVEL OF EVIDENCE

4.

Promoting Responsible Electronic Documentation: Validity Evidence for a Checklist to Assess Progress Notes in the Electronic Health Record

Construct: We aimed to develop an instrument to measure the quality of inpatient electronic health record- (EHR-) generated progress notes without requiring raters to review the detailed chart or know the patient.

BACKGROUND

Notes written in EHRs have generated criticism for being unnecessarily long and redundant, perpetuating inaccuracy and obscuring providers' clinical reasoning. Available assessment tools either focus on outpatient progress notes or require chart review by raters to develop familiarity with the patient.

APPROACH

We used medical literature, local expert review, and attending focus groups to develop and refine an instrument to evaluate inpatient progress notes. We measured interrater reliability and scored the selected-response elements of the checklist for a sample of 100 progress notes written by PGY-1 trainees on the general medicine service.

RESULTS

We developed an instrument with 18 selected-response items and four open-ended items to measure the quality of inpatient progress notes written in the EHR. The mean Cohen's kappa coefficient demonstrated good agreement at .67. The mean note score was 66.9% of maximum possible points (SD = 10.6, range = 34.4%-93.3%).

CONCLUSIONS

We present validity evidence in the domains of content, internal structure, and response process for a new checklist for rating inpatient progress notes. The scored checklist can be completed in approximately 7 minutes by a rater who is not familiar with the patient and can be done without extensive chart review. We further demonstrate that trainee notes show substantial room for improvement.

Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Project

OBJECTIVE

Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas.

STUDY SETTING

In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts.

STUDY DESIGN

Controlled trial of a 15-month intervention including exposure to a learning network, webinars, face-to-face meetings, and coaching by improvement advisors targeting "3+1" high-risk domains: test result, referral, and medication management plus culture/communication issues evaluated by survey and chart review tools.

DATA COLLECTION METHODS

Chart reviews conducted at baseline and postintervention for intervention sites. Staff and patient survey data collected at baseline and postintervention for intervention and control sites.

PRINCIPAL FINDINGS

Chart reviews demonstrated significant improvements in documentation of abnormal results, patient notification, documentation of an action or treatment plan, and evidence of a completed plan (all P<0.001). Mean days between laboratory test date and evidence of completed action/treatment plan decreased by 19.4 days (P<0.001). Staff surveys showed modest but nonsignificant improvement for intervention practices relative to controls overall and for the 3 high-risk domains that were the focus of PROMISES.

CONCLUSIONS

A consortium of stakeholders, quality improvement tools, coaches, and learning network decreased selected ambulatory safety risks often seen in malpractice claims.

Electronic health records: Is it a risk worth taking in healthcare delivery?

The electronic health record represents a major change in healthcare delivery, either for health professionals and health institutions, either for patients.

In this essay we will mainly focus on its consequences regarding patient safety and medical liability. In this particular domain the electronic health record has dual effects: on one side prevents medical errors and, in this sense, promotes patient safety and protects the doctor from lawsuits; but, on the other side, when not used properly, it may also generate other kind of errors, potentially threatening patient safety and, therefore, increasing the risk of juridical liability for the physician.

This paper intends to underline the main human errors, technologic mistakes and medical faults that may occur while using the electronic health record and the ways to overcome them, also explaining how the electronic health record may be used in court during a judicial proceeding.

Ordo ab Chao: framework for an integrated disease report

CONTEXT

The volume of information that must be assimilated to appropriately manage patients with complex or chronic disease can make this task difficult because of the number of data points, their variable temporal availability, and the fact that they may reside in different systems or even institutions. OBJECTIVE .- To outline a framework for building an integrated disease report (IDR) that takes advantage of the capabilities of electronic reporting to create a single, succinct, interpretative report comprising all disease pertinent data.

DESIGN

Disease pertinent data of an IDR include pathology results, laboratory and radiology data, pathologic correlations, risk profiles, and therapeutic implications. We used cancer herein as a representative process for proposing what is, to our knowledge, the first example of standardized guidelines for such a report. The IDR was defined as a modular, dynamic, electronic summary of the most current state of a patient in regard to a particular illness such as lung cancer or diabetes, which includes all information relevant for patient management.

RESULTS

We propose the following 11 core data concepts that an IDR should include: patient identification; patient demographics; disease, diagnosis, and prognosis; tumor board dispositions and decisions; graphic timeline; preresection workup and therapy; resection workup; interpretative comment summarizing pertinent findings; biobanking data; postresection workup; and disease and patient status at follow-up.

CONCLUSIONS

A well-executed IDR should improve patient care and efficiency for health care team members. It would demonstrate the added value of pathology interpretation and likely contribute to a reduction in errors and improved patient safety by decreasing the risk that important data will be overlooked.

If you did not document it, it did not happen: rates of documentation of discussion of infertility risk in adolescent and young adult oncology patients' medical records

PURPOSE

The adolescent and young adult (AYA) population is underserved because of unique late-effect issues, particularly future fertility. This study sought to establish rates of documentation of discussion of risk of infertility, fertility preservation (FP) options, and referrals to fertility specialists in AYA patients' medical records at four cancer centers.

METHODS

All centers reviewed randomized records within the top four AYA disease sites (breast, leukemia/lymphoma, sarcoma, and testicular). Eligible records included those of patients: diagnosed in 2011, with no prior receipt of gonadotoxic therapy; age 18 to 45 years; with no multiple primary cancers; and for whom record was not second opinion. Quality Oncology Practice Initiative methods were used to evaluate documentation of discussion of risk of infertility, discussion of FP options, and referral to a fertility specialist.

RESULTS

Of 231 records, 26% documented infertility risk discussion, 24% documented FP option discussion, and 13% documented referral to a fertility specialist. Records were less likely to contain evidence of infertility risk and FP option discussions for female patients (P = .030 and .004, respectively) and those with breast cancer (P = .021 and < .001, respectively). Records for Hispanic/Latino patients were less likely to contain evidence of infertility risk discussion (P = .037). Records were less likely to document infertility risk discussion, FP option discussion, and fertility specialist referral for patients age ≥ 40 years (P < .001, < .001, and .002, respectively) and those who already had children (all P < .001).

CONCLUSION

The overall rate of documentation of discussion of FP is low, and results show disparities among specific groups. Although greater numbers of discussions may be occurring, there is a need to create interventions to improve documentation.

Electronic health records, adoption, quality of care, legal and privacy issues and their implementation in emergency departments

Recently, the healthcare sector has shown a growing interest in information technologies. Two popular health IT (HIT) products are the electronic health record (EHR) and health information exchange (HIE) networks. The introduction of these tools is believed to improve care, but has also raised some important questions and legal and privacy issues. The implementation of these systems has not gone smoothly, and still faces some considerable barriers. This article reviews EHR and HIE to address these obstacles, and analyzes the current state of development and adoption in various countries around the world. Moreover, legal and ethical concerns that may be encountered by EHR users and purchasers are reviewed. Finally, links and interrelations between EHR and HIE and several quality of care issues in today's healthcare domain are examined with a focus on EHR and HIE in the emergency department (ED), whose unique characteristics makes it an environment in which the implementation of such technology may be a major contributor to health, but also faces substantial challenges. The paper ends with a discussion of specific policy implications and recommendations based on an examination of the current limitations of these systems.

Electronic medical records in colorectal surgery

Electronic medical records (EMRs) are being widely implemented today, either as stand-alone applications in smaller practices or as systems-based integrated network solutions in larger health care organizations. Advantages include rapid accessibility, worldwide availability, ease of storage, and secure transfer of protected health information (PHI). Computerized physician order entry (CPOE) and decision-support capabilities such as the triggering of an alarm when multiple medications with known interactions are ordered, as well as the seemingly endless possibilities for electronic integration and extraction of PHI for clinical and research purposes, have created opportunities and pitfalls alike. Risks include breaches of confidentiality with a need to implement tighter measures for electronic security. These measures contrast efforts required for the realization of common data formats that have national and even international compatibility. EMRs provide a common platform that could potentially allow for the integration and administration of clinical care, research, and quality metrics, thus promoting optimal outcomes for patients. Technical and medicolegal difficulties need to be overcome in the years to come so that the safe use of PHI can be ensured while still maintaining the benefits and convenience of modern EMR systems.

Electronic medical records and quality of cancer care

The implementation of electronic medical records (EMR) systems was mandated by the U.S. federal government in large part due to research indicating that difficulty accessing clinical data was one of the most common causes of preventable deaths. Several assumptions were implicit in this mandate, including the assumption that the implementation of EMR would indeed improve clinicians' access to clinical data, that implementation of EMR would pose little to no risk to patients, and that the clinical benefit of improved access to clinical data would outweigh any risks that might arise. As detailed in this review, both formal research and extensive experiential observation have called all three assumptions into question. Specifically, as detailed below, there is clear evidence that EMR systems are associated with multiple specific risks to patients, whereas few, if any, scientifically rigorous outcomes-based studies have demonstrated that the potential benefits of EMR outweigh the known risks. In addition, there is currently little to no scientifically rigorous evidence that EMR systems constitute a cost-effective methodology for improving patient outcomes.

Effectiveness of a medicolegal lecture on risk-reduction medical record documentation by pediatric residents

OBJECTIVE

To determine the effectiveness of a medicolegal lecture on risk-reduction documentation by residents in a pediatric emergency department.

DESIGN/METHODS

Pediatric residents at an academic children's hospital were offered a 1-hour lecture on reducing medicolegal risks. Residents in attendance made up the intervention group (IG) and nonattendants were the control group (CG). The primary outcome was risk-reduction documentation (RRD) using patients with chief complaints of abdominal pain, extremity fractures, and lacerations with potential foreign body.

RESULTS

For abdominal pain patients, RRD by IG improved 6.1% compared with 15.1% for the CG. For fracture patients, RRD by IG improved 20% compared with 26.5% decrease by CG. For laceration patients, RRD by IG decreased 20.8% compared with 30.6% decrease by CG. Although none reached statistical significance, the postintervention IG rates were greater.

CONCLUSIONS

We showed a trend toward improvement in the rate of risk-reduction medical record documentation.

An assessment of the dementia CQUIN--an audit of improving compliance

The Department of Health has increased the emphasis on earlier detection of dementia among patients aged over 75 admitted to hospital in an emergency in England. Introduction of a Commissioning for Quality and Innovation (CQUIN) payment provides an incentive for NHS Trusts to screen patients for memory problems on admission. This article reports on how improvements were made to the screening process across three wards in a large university teaching hospital.

Attitudes of Jewish and Bedouin responders toward family physicians' use of electronic medical records during the medical encounter

OBJECTIVE

Culture is known to impact expectations from medical treatments. The effects of cultural differences on attitudes toward Electronic Medical Records (EMR) have not been investigated. We compared the attitudes of Jewish and Bedouin responders toward EMR's use by family physicians during the medical encounter, and examined the contribution of background variables to these attitudes.

METHODS

86 Jewish and 89 Bedouin visitors of patients in a regional Israeli University Medical Center responded to a self-reporting questionnaire with Hebrew and Arabic versions.

RESULTS

T-tests and a linear regression analysis found that culture did not predict attitudes. Respondents' self-reported health status, Internet and e-mail use, and estimates of their physician's typing speed explained a total of 18.6% of the variance in attitudes (p<0.001).

CONCLUSION

Bedouins respondents' attitudes toward EMR use were better than expected and similar to those of their Jewish counterparts. The most significant factor influencing respondents' attitudes was the physician's typing speed.

PRACTICE IMPLICATIONS

(1) Further studies should consider the possible impact of cultural differences between the family physician and the healthcare client on attitudes. (2) Interventions to improve physicians' skill in operating EMRs and typing will potentially have a positive impact on patients' satisfaction with physicians' EMR use.

4000 clicks: a productivity analysis of electronic medical records in a community hospital ED

OBJECTIVE

We evaluate physician productivity using electronic medical records in a community hospital emergency department.

METHODS

Physician time usage per hour was observed and tabulated in the categories of direct patient contact, data and order entry, interaction with colleagues, and review of test results and old records.

RESULTS

The mean percentage of time spent on data entry was 43% (95% confidence interval, 39%-47%). The mean percentage of time spent in direct contact with patients was 28%. The pooled weighted average time allocations were 44% on data entry, 28% in direct patient care, 12% reviewing test results and records, 13% in discussion with colleagues, and 3% on other activities. Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters. Total mouse clicks approach 4000 during a busy 10-hour shift.

CONCLUSION

Emergency department physicians spend significantly more time entering data into electronic medical records than on any other activity, including direct patient care. Improved efficiency in data entry would allow emergency physicians to devote more time to patient care, thus increasing hospital revenue.

Computer Physician Order Entry (CPOE)

In an effort to reduce Adverse Drug Events (ADEs) and to improve patient safety, funding has been earmarked to improve the rate of adoption of Computerized Physician Order Entry (CPOE) among healthcare providers. It has been shown that the ordering stage of medications is where most medication errors and preventable ADEs occur. The purpose of this study was to examine the implementation CPOE systems in hospitals to determine benefits and concerns of this technology in the United States healthcare system. A review of the literature published in the last 13 years (since 2000) in the English language was performed to complete this investigation. CPOE has emerged as a valuable tool to improve medical efficiency and to decrease medication errors and ADEs. Efficiencies were found to reduce the overall workload of nurses, clerical workers and pharmacists. CPOE has proven to be a secure way of transferring physician orders electronically thus helping hospitals and physicians practice a more effective and better quality of care with less medical errors which has led to decreased operating expenses. While barriers such as lack of professional buy in, and cost of implementation have hindered the widespread use and growth of CPOE systems, these barriers are being overcome with the financial incentives from the HITECH Act, and with the increased savings of CPOE implementation, which may motivate more healthcare systems to adopt CPOE.

The ethics of health information technology in oncology: emerging isssues from both local and global perspectives

Health information technology (HIT) is ever-increasing in complexity and has incrementally become a fundamental part of our everyday clinical lives. As HIT becomes more complex and commonplace, so do the questions it raises about stewardship and usage of data, along with the ethics of these applications. With the development of rapid-learning systems, such as ASCO's CancerLinQ, careful thought about the ethics and applications of these technologies is necessary. This article uses the principles-based framework of modern bioethics to examine evolving ethical issues that arise in the context of HIT and also discusses HIT's application in reducing cancer care disparities in the developing world. We recognize that this topic is quite broad, so here we provide an overview of the issues, rather than any definitive conclusions about a particular "correct path." Our hope is to stimulate discussion about this important topic, which will increasingly need to be addressed in the oncology community.

Impact of electronic health records on malpractice claims in a sample of physician offices in Colorado: a retrospective cohort study

BACKGROUND

Electronic health records (EHRs) might reduce medical liability claims and potentially justify premium credits from liability insurers, but the evidence is limited.

OBJECTIVES

To evaluate the association between EHR use and medical liability claims in a population of office-based physicians, including claims that could potentially be directly prevented by features available in EHRs ("EHR-sensitive" claims).

DESIGN

Retrospective cohort study of medical liability claims and analysis of claim abstracts.

PARTICIPANTS

The 26 % of Colorado office-based physicians insured through COPIC Insurance Company who responded to a survey on EHR use (894 respondents out of 3,502 invitees).

MAIN MEASURES

Claims incidence rate ratio (IRR); prevalence of "EHR-sensitive" claims.

KEY RESULTS

473 physicians (53 % of respondents) used an office-based EHR. After adjustment for sex, birth cohort, specialty, practice setting and use of an EHR in settings other than an office, IRR for all claims was not significantly different between EHR users and non-users (0.88, 95 % CI 0.52-1.46; p = 0.61), or for users after EHR implementation as compared to before (0.73, 95 % CI 0.41-1.29; p = 0.28). Of 1,569 claim abstracts reviewed, 3 % were judged "Plausibly EHR-sensitive," 82 % "Unlikely EHR-sensitive," and 15 % "Unable to determine." EHR-sensitive claims occurred in six out of 633 non-users and two out of 251 EHR users. Incidence rate ratios were 0.01 for both groups.

CONCLUSIONS

Colorado physicians using office-based EHRs did not have significantly different rates of liability claims than non-EHR users; nor were rates different for EHR users before and after EHR implementation. The lack of significant effect may be due to a low prevalence of EHR-sensitive claims. Further research on EHR use and medical liability across a larger population of physicians is warranted.

The introduction of the national e-health record into Australian community pharmacy practice: pharmacists' perceptions

OBJECTIVE

Personally Controlled Electronic Health Records (PCEHRs) were introduced for Australian health consumers in July 2012. This study aimed to determine, in the months prior to the launch, community pharmacists' perceptions about practical and professional aspects relating to integration of the PCEHR into pharmacy practice, with a view to informing practice guidelines and training.

METHODS

Semi-structured interviews with 25 pharmacy owners and/or managers from 24 community pharmacies in Perth, Western Australia, were undertaken during March-April 2012. Participants were given a standardised briefing about the PCEHR before exploratory questioning regarding the expected integration, benefits and challenges of the system in pharmacy practice.

KEY FINDINGS

Despite some awareness of the impending introduction of PCEHRs via the lay media, pharmacists were almost unanimously uninformed about the intended rollout, design and functionality of the system for health consumers and practitioners. Participants expressed concerns regarding patients' control over their data management, time associated with staff training, technical upgrades and resource allocation. Obstacles included pharmacists' inability to legitimately access patient data outside consultations. Pharmacists expected flexibility to record clinical activities and health services. Priorities identified for the profession were remuneration, medico-legal guidelines and boundaries, and clarification of roles and responsibilities.

CONCLUSIONS

Despite being unaware of details surrounding integration of PCEHRs in practice, community pharmacists provided insights into their expectations and concerns and the perceived benefits relating to implementation of the system. Training priorities and practice guidelines should address ethical data management and optimal use of electronic health records for clinical services.

Clinical decision support systems could be modified to reduce 'alert fatigue' while still minimizing the risk of litigation

Clinical decision support systems--interactive computer systems that help doctors make clinical choices--can reduce errors in drug prescribing by offering real-time alerts about possible adverse reactions. But physicians and other users often suffer "alert fatigue" caused by excessive numbers of warnings about items such as potentially dangerous drug interactions. As a result, they may pay less attention to or even ignore some vital alerts, thus limiting these systems' effectiveness. Designers and vendors sharply limit the ability to modify alert systems because they fear being exposed to liability if they permit removal of a warning that could have prevented a harmful prescribing error. Our analysis of product liability principles and existing research into the use of clinical decision support systems, however, finds that more finely tailored or parsimonious warnings could ease alert fatigue without imparting a high risk of litigation for vendors, purchasers, and users. Even so, to limit liability in this area, we recommend stronger government regulation of clinical decision support systems and development of international practice guidelines highlighting the most important warnings.

Secondary uses of electronic health record data: benefits and barriers

In the primary use of health data, patient health information in electronic health records (EHRs) directly informs each individual's care. In secondary use, patient data would be aggregated to improve health care delivery, yet several technological and policy barriers may slow implementation-but may be amenable to intervention.

Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging

BACKGROUND

Gastrostomy tube (g-tube) dislodgement is a common problem in special needs children. There are no studies on the frequency of complications after g-tube replacement for children in a pediatric emergency department (ED).

OBJECTIVES

The objective of this study is to determine the frequency of misplacement and subsequent complications for children undergoing g-tube replacement in a pediatric ED and the impact of contrast-enhanced confirmatory imaging on ED length of stay (LOS).

METHODS

This was a retrospective review of children presenting to a pediatric ED over 16 months. Subjects were included if they underwent g-tube replacement in the ED. Records were reviewed for historical and procedural data including patient age, g-tube age, ED LOS, documented difficulties replacing the tube, performance of confirmatory imaging (contrast-enhanced radiograph), and complications identified within 72 hours of ED visit.

RESULTS

A total of 237 children met inclusion criteria. Three (1.2%) had evidence of g-tube misplacement, all of whom underwent confirmatory imaging. One complication from misplacement was identified (gastric outlet obstruction from overfilled balloon). Tract disruption was not identified for any subject. Eighty-four subjects (35%) had confirmatory imaging performed after replacement. Mean ED LOS in the imaged group was 265 vs 142 minutes for the nonimaged group (P < .001). No subjects with documentation of clinical confirmation had subsequent evidence of misplacement.

CONCLUSIONS

For children undergoing g-tube replacement in a pediatric ED, misplacement and associated complications were rare. Confirmatory imaging was associated with a considerably longer LOS. In the presence of clinical confirmation, confirmatory imaging may be judiciously used.

Defining health information technology-related errors: new developments since to err is human

Despite the promise of health information technology (HIT), recent literature has revealed possible safety hazards associated with its use. The Office of the National Coordinator for HIT recently sponsored an Institute of Medicine committee to synthesize evidence and experience from the field on how HIT affects patient safety. To lay the groundwork for defining, measuring, and analyzing HIT-related safety hazards, we propose that HIT-related error occurs anytime HIT is unavailable for use, malfunctions during use, is used incorrectly by someone, or when HIT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted. These errors, or the decisions that result from them, significantly increase the risk of adverse events and patient harm. We describe how a sociotechnical approach can be used to understand the complex origins of HIT errors, which may have roots in rapidly evolving technological, professional, organizational, and policy initiatives.

A secure protocol for protecting the identity of providers when disclosing data for disease surveillance

BACKGROUND

Providers have been reluctant to disclose patient data for public-health purposes. Even if patient privacy is ensured, the desire to protect provider confidentiality has been an important driver of this reluctance.

METHODS

Six requirements for a surveillance protocol were defined that satisfy the confidentiality needs of providers and ensure utility to public health. The authors developed a secure multi-party computation protocol using the Paillier cryptosystem to allow the disclosure of stratified case counts and denominators to meet these requirements. The authors evaluated the protocol in a simulated environment on its computation performance and ability to detect disease outbreak clusters.

RESULTS

Theoretical and empirical assessments demonstrate that all requirements are met by the protocol. A system implementing the protocol scales linearly in terms of computation time as the number of providers is increased. The absolute time to perform the computations was 12.5 s for data from 3000 practices. This is acceptable performance, given that the reporting would normally be done at 24 h intervals. The accuracy of detection disease outbreak cluster was unchanged compared with a non-secure distributed surveillance protocol, with an F-score higher than 0.92 for outbreaks involving 500 or more cases.

CONCLUSION

The protocol and associated software provide a practical method for providers to disclose patient data for sentinel, syndromic or other indicator-based surveillance while protecting patient privacy and the identity of individual providers.

Legal, ethical, and financial dilemmas in electronic health record adoption and use

Electronic health records (EHRs) facilitate several innovations capable of reforming health care. Despite their promise, many currently unanswered legal, ethical, and financial questions threaten the widespread adoption and use of EHRs. Key legal dilemmas that must be addressed in the near-term pertain to the extent of clinicians' responsibilities for reviewing the entire computer-accessible clinical synopsis from multiple clinicians and institutions, the liabilities posed by overriding clinical decision support warnings and alerts, and mechanisms for clinicians to publically report potential EHR safety issues. Ethical dilemmas that need additional discussion relate to opt-out provisions that exclude patients from electronic record storage, sale of deidentified patient data by EHR vendors, adolescent control of access to their data, and use of electronic data repositories to redesign the nation's health care delivery and payment mechanisms on the basis of statistical analyses. Finally, one overwhelming financial question is who should pay for EHR implementation because most users and current owners of these systems will not receive the majority of benefits. The authors recommend that key stakeholders begin discussing these issues in a national forum. These actions can help identify and prioritize solutions to the key legal, ethical, and financial dilemmas discussed, so that widespread, safe, effective, interoperable EHRs can help transform health care.