One of the major changes that I have witnessed in my career, first as a hospital administrator, and now for almost 20 years as a Houston, Texas medical malpractice lawyer, is the transition from paper medical records to electronic medical records.
I cannot remember speaking to anyone in medicine, nursing, or law who believes that electronic medical records are a step forward when it comes to taking care of patients. The only advantage that I see is that electronic records are easy to read and search; however, a chart that used to be 100-200 pages can now easily be 10 times that amount because of unnecessarily-repeated information that is auto-populated by the software.
In my experience, electronic medical records pose additional challenges to patient safety. Two of them are illustrated in a medical malpractice lawsuit that I am currently handling in Harris County, Texas, involving care provided to a patient at a hospital in Humble that is part of a major regional healthcare brand.
First, electronic medical record (EMR) systems often have clickable circles or boxes and pull-down menus, as opposed to a space for narrative notes. In this current lawsuit, the defendant emergency room (ER) physician ordered a head CT scan because of my client’s severe headache. Even though the ER doctor realized that it was not a “completely accurate” description, he explained in his deposition that he selected the closest option in the drop-down menu, which was “headache with dizziness and giddiness.”
This incomplete, inaccurate information was the only clinical information available to the defendant neuroradiologist, who was not located in the hospital and read the CT scan off-site. If the EMR system allowed a narrative note to accompany the CT order, the ER physician could have explained that the clinical indication for the scan was the worst headache of the patient’s life, accompanied by nausea, vomiting, and visual disturbance. Our medical experts believe that this additional information would have been helpful to the neuroradiologist, and may have prevented her from completely misreading the scan.
The second EMR problem that I noticed in this lawsuit is the role of medical scribes. Because of the additional administrative time that it requires to document physician notes in an electronic system, many doctors are using employees, called scribes, to write their notes into the medical record. According to some recent research, almost 20% of physicians currently use scribes, and another 10% plan on hiring them soon.
In the current lawsuit that we have been discussing, my client had gone to an emergency room three days in a row with what he described as a headache that was different from anyone he had previously experienced. Any time a patient says something like this, or that he is experiencing the worst headache of his life, it should get a physician’s attention.
On the second day that the patient went to the emergency room, the ER physician and nurse practitioner clearly documented this fact in the medical record. On the third ER visit in three days, the ER physician utilized a scribe, who wrote in the medical record that the patient described his headache as “similar to previous headaches.” The patient and his wife said that this was clearly a mistake. The ER doctor has no recollection of it, but testified at deposition that his scribe absolutely had to be right, instead of the patient.
One of the surprising facts about scribes is there they have no measurable or standardized training and competency. This means that scribes vary in their training and knowledge concerning basic medical terminology, how to write physician notes and orders, and the basics of how electronic medical records work.
Recent research shows that 55% of scribes are trained by the physician and 44% have no prior healthcare experience. This alarms me, given that scribes with minimal or limited training are writing physician orders and notes that are relied on in the care of patients.
The Joint Commission, an accrediting agency for hospitals, stepped in to require that all scribe-generated orders be signed by the physician before they were implemented, and any entries in electronic medical records be authenticated by the doctor. While these requirements are a good first step, it is not realistic to expect that a busy physician will carefully review narrative electronic medical record entries made by a scribe. Thus, I believe these records are unreliable and prone to error.
What you can do
When interacting with a physician, physician’s assistant, or nurse practitioner, pay attention and notice whether another person is taking the notes. If so, be sure to speak up and speak clearly to improve the odds that your information is being recorded correctly.
In addition, because of the questionable reliability of electronic medical record information entered by scribes, I recommend repeating as much information as possible about your condition, symptoms, and questions each time you see a healthcare provider. This practice should help reduce the risk that a scribe makes a significant mistake, or that a doctor relies on incorrect information from a scribe.
Any time I prepare a client for deposition, I emphasize that just because the medical record says something, do not take it for granted that it is true. Almost every record contains multiple errors and I believe this will become even more commonplace as the role of scribes increases.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2017, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.