Perspective: A critical review of “click-tation” in EHR’s

Electronic Health Records (EHR’s): A “critical” review
By Charles A. Pilcher MD FACEP
March, 2017

The purpose of a medical record is to record information about a patient for future reference or to communicate information to other caregivers. EHR’s have failed at both.

It’s been 2 1/2 years since Neil Chesanow, Senior Editor of Medscape Business of Medicine, published a lengthy review of the legal dangers of EHR’s. Little has changed in that time. Chesanow provided eight ways in which EHR’s can be a factor in malpractice lawsuits. Each is something I have personally encountered as I have participated in medicine’s transition from paper to electronic records. This “Perspective” briefly summarizes Chesanow’s eight points.

Early in my career the only problem with reviewing records was reading the handwriting. Now, a 3 day hospital stay may generate over 500 pages of records without a single handwritten entry. “Click-tation” has replaced dictation. Yes, now they’re easy to read, but within those hundreds of pages of “documentation,” only 1-5% of the material communicates any useful information. They provide little evidence that the patient was actually cared for – with “care” being the operative word. For example, in the past week I received a USB drive with 2402 pages from a hospital chart. It took me less than 30 minutes to scan more than 2300 of those pages and eliminate them as absolutely useless. Page after page of information either downloaded automatically from a monitor or created for nothing more than to comply with regulations. Less than 5% of the chart contained potentially usable information.

Chesanow’s review identifies 8 legal risks associated with EHR’s.

  1. The EHR Itself: What if the EHR itself is poorly designed, hard to use or just doesn’t work as claimed. Who’s to blame? What if entered data disappears due to a system flaw or software update? Because vendors write their contracts to absolve themselves of liability, the individual physician or practice shoulders it all. That principle is even enshrined in HIPAA. That said, a hospital or clinic that is aware of a flaw should either fix it or document efforts to have the vendor do so.
  2. Copy/Paste: EHR’s slow doctors down. They mandate entries that doctors think are “busy work.” To overcome that, doctors find shortcuts. Ccopy/paste is the most common, because it’s a way for providers to insert more information and justify a higher level billing code. Copy/paste is easy to spot, and a record that shows it points to a provider who cares less about accuracy than productivity. He or she may not appear to care at all. Records become so bloated that the wheat is lost amongst the chaff. Outdated or inaccurate information causes one to ask “What other shortcuts did the provider take to take?” The only real solution is to disable copy/paste if the system allows it. In addition, most EHR’s have “macros” that will generate an entire paragraph of text by clicking a single box. Surgeons use this for documenting “informed consent.” As I review these charts, I find many of the entries un-believable. One provably erroneous entry – and they are present in 84% of charts – casts doubt on the entire record. This means that a defense attorney will have to ask “Are you calling my doctor a liar?” To which the only appropriate answer is “That will be for the jury to decide.” Maybe? Maybe not.
  3. Passwords: Everyone using an EHR should use a personal password. Sharing passwords or leaving screens unattended results in entries being attributed to the wrong provider. One cannot say “That wasn’t me” if the screen was open and someone else entered data. Another problem is that using a computer “off network,” especially a password protected one, to surf the web exposes a practice’s IT system and EHR to password theft, identity theft, hackers, ransomware, altered records and compromised private information. Personal passwords at least allow identification of the culprit.
  4. Clinical Decision Support (CDS): Many EHR’s have clinical decision support tools. These are pre-programmed algorithms that display “pop-ups” for things like the differential diagnosis for a certain set of symptoms, drug allergies and interactions or recommended tests. CDS help or warnings are so broad that they cause “alert fatigue,” at which point providers simply “click through” and pay no attention – sometimes at their peril. Some users turn off or “dumb down” the CDS in the EHR, setting up a potential gold mine for a plaintiff attorney. Everything is tracked and, just like Santa Claus, the EHR “knows when you’ve been bad or good.” Its audit trail or “metadata” can doom a provider involved in a lawsuit by showing who clicked what and for how long.
  5. Non-Standard Use of the EHR: In an effort to “make this damn thing more useful,” providers may be tempted to “customize” the software” to alter the way some of the annoying check boxes behave. “Have you made any modifications to your EHR?” is a likely question from a plaintiff attorney. If the answer is “Yes,” and a provider has bypassed the original design, the doo-doo starts getting deep.
  6. EHRs  and the Standard of Care: Because of something called “meaningful use,” certain features of EHR’s have been mandated by the Center for Medicare and Medicaid Services (CMS). Thus, things like checking for drug allergies and interactions have become the de facto standard of care – and providers violate it at their peril.
  7. GIGO: The Legal Consequences of Bad Input: EHR’s have not made practices more efficient. The opposite is true. Physicians say that their workday has increased by 10-20% because of the time it takes to enter data into the EHR. Doctors either work longer or reduce the face-to-face time with the patient. Or when in the exam room, they focus on the computer, not the patient. Shortcuts like these lead to incomplete patient histories, a limited physical exam, not reviewing old records, medications, or allergies, etc. Thus, the complete picture of the patient’s problem can be missed. The amount of verbiage can be huge, but meaningful information and communication is absent. There is no longer any “color” in charts; they look like they were completed by robots. It’s all too easy to play “click-a-box” and indicate that something was done when other entries show that it wasn’t. Conversely, it’s easy to overlook clicking a box that is meaningful information. The nurse may write “patient fell at home and is unable to walk.” The physician doesn’t see that note, misses that information, and either never gets the patient off the exam table and/or accidentally clicks “Neuro exam and gait normal.”
  8. The “Robot Effect”: Patients dislike providers who spend more time with data entry than they do with them. True communication is disappearing, just as text messaging is replacing conversation. Patients feel that providers don’t care. They are disgruntled, and an unhappy patient is more likely to sue… and rightfully so, since the inattentive provider is more likely to make a mistake. While e-visits are becoming popular, failure to respond quickly or in an emergency or responding flippantly can lead to a bad outcome, an unhappy patient and a lawsuit.

The complete Medscape article (subscription may be necessary) by Chesanow can be found here. References can be found at the end of the article or by clicking on any superscript reference.

Dr. Michael Victoroff of COPIC has an illustrative powerpoint presentation that is full of examples of the foibles of EHR’s. Take a look here.

You might also enjoy reading “Epic Finger,” a tongue-in-cheek tale of the digital (as in fingers) damage done by digital (as in electronic) documentation, or “click-tation” in Annals of Emergency Medicine, January, 2017.

Finally, Chesanow quotes 2 experts on EHR’s, should you ever wish to consult one, though the record usually speaks for itself:

  • Sharona Hoffman, JD, Professor of Law & Bioethics, Case Western School of Law, Cleveland, Ohio
  • Ronald B. Sterling CPA MBA, EHR expert, Silver Spring, Maryland, author of Keys to EMR Success.


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