As technological advances become more commonplace in modern American medical culture, electronic health records (EHRs) are quickly becoming standard. Medical professionals and patients alike have come to appreciate the clarity and ease offered by EHRs. However, in the courtroom, certain questions and complications arise regarding the validity of EHRs as evidence. Misdiagnosis and medication errors have been traced to both EHR system errors and human error. With over 2,000 regulations governing these systems, the legalities of EHRs are still being tested in court as each new circumstance presents itself.
Threats to Patient Safety
Medical mistakes originating from documentation can lead to a number of adverse issues affecting patient safety. Electronic health record programs are designed to follow a specific order of documentation. If information has not yet been entered into the system because a nurse is waiting for a doctor’s electronic prompt, for example, it may be overlooked altogether. These miscommunications among medical care staff could result in medication error or misdiagnosis.
Fortunately, EHRs have certain system alerts as part of their programming that function as red flags for practitioners. Potential dangers such as negative drug interactions or contraindications can be helpful in preventing harm to patients. However, glitches in the system, design flaws, or poor programming can cause specific alerts to malfunction. As with computer databases, entire systems can fail resulting in dangerous levels of miscommunication and confusion among medical staff.
While system and program defects account for a number of malpractice cases, human errors with EHRs can also have devastating effects, including:
- Data entry mistakes leading to severe safety issues
- Lack of proofreading automatic refill screens and default templates may lead to safety hazards such as medication error
- Copy-and-paste mistakes cause potentially dangerous misdocumentation
- Improper training can lead to any number of mistakes or misuse of the program
As HIPPA legislation is still a vital element in a patient’s right to privacy, many have expressed concerns over the security of their medical history. Threats lie in both the ease of access for unauthorized medical staff, as well as the risk of system compromise due to malicious hackers. Even though records are considered confidential between a patient and doctor, they can easily be accessed by a staff member in another department for valid and erroneous reasons. Similarly, medical programs are vulnerable to breach just as much as corporate and government databases.
Complications in the Courtroom
Some issues affecting litigation include the following:
- EHRs qualify as documentation despite any combination of technological or human error.
- The amount of data able to be stored in EHRs far exceeds handwritten records which allows for the potential to overlook vital information pertaining to a case.
- Guidelines for clinical decisions are programmed into EHR systems, which are meant to assist in providing relevant alerts. In some cases, these alerts are associated with medical ‘standards of care.’ However, a physician may override an alert based on the circumstances of an individual case, creating a large gray area in legal interpretation. A physician may be liable for malpractice if he or she overrides the EHR’s standard of care, but who determines that standard is still in question.
Berkowitz and Hanna LLC – Serving Fairfield, Hartford, and New Haven Counties
Experiencing illness or injury as a result of medical malpractice can result in financial, physical and emotional distress. At Berkowitz and Hanna LLC, our medical malpractice attorneys will be your greatest advocate. We have an impressive record of obtaining compensation for our clients, and we want to help you get the recourse you deserve. With offices throughout Connecticut, we are available to discuss your unique circumstances and help you determine the best way to move forward. Contact us today for a free consultation.