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Gordon Wallace`s Panel Presentation
EMR Pitfalls to Avoid eSummit Safety Dr. Gordon Wallace, FRCPC Managing Director Safe Medical Care © The Canadian Medical Protective Association cmpa-acpm.ca Faculty / Presenter Disclosure Faculty: Gordon Wallace Employee of: CMPA (not-for-profit mutual defence association) Relationships with commercial interests: - Grants / Research Support: None________________________ - Speakers Bureau / Honoraria: None________________________ - Consulting Fees: None________________________ - 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 owner as per license agreements – Thinkstock, YouTube and others as required. © The Canadian Medical Protective Association cmpa-acpm.ca How EMRs Improve Patient Care © The Canadian Medical Protective Association cmpa-acpm.ca The Good • Fixes legibility of handwriting 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 Information given to patient © The Canadian Medical Protective Association cmpa-acpm.ca Despite advantages, Medico-legal risks are emerging © The Canadian Medical Protective Association cmpa-acpm.ca What Will We Accomplish Today ? • Identify common pitfalls and medico-legal risks associated with EMR use • Describe strategies to mitigate these risks © The Canadian Medical Protective Association cmpa-acpm.ca Cases and Lessons 1 Privacy breaches Lost records © The Canadian Medical Protective Association cmpa-acpm.ca I’ve lost it! © The Canadian Medical Protective Association cmpa-acpm.ca I’ve lost it! Lost or stolen • • • • Laptops Office computer systems CDs and DVDs Memory sticks, portable USB drives © The Canadian Medical Protective Association cmpa-acpm.ca I’ve lost it! Solution • Passwords not enough – Electronic medical records = Think encryption – Mobile devices = Think encryption © The Canadian Medical Protective Association cmpa-acpm.ca Cases and Lessons 2 Privacy breaches Viewing © The Canadian Medical Protective Association cmpa-acpm.ca Privacy breaches © The Canadian Medical Protective Association cmpa-acpm.ca Privacy breaches Time of care Time documented AUDIT TRAIL Which documents were viewed and for how long Any changes or additions Time spent viewing a lab test or diagnostic image © The Canadian Medical Protective Association cmpa-acpm.ca Privacy breaches 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 © The Canadian Medical Protective Association cmpa-acpm.ca Privacy breaches 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 Training, training manual and confidentiality agreement for staff © The Canadian Medical Protective Association cmpa-acpm.ca Privacy breaches 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 © The Canadian Medical Protective Association cmpa-acpm.ca Privacy breaches Password Security © The Canadian Medical Protective Association cmpa-acpm.ca Privacy breaches 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! Intrusion Upon Seclusion Invasion of privacy = $10,000 damages! © The Canadian Medical Protective Association cmpa-acpm.ca Cases and Lessons 3 Interface design © The Canadian Medical Protective Association cmpa-acpm.ca Interface 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: © The Canadian Medical Protective Association cmpa-acpm.ca Don’t Forget To Scroll Down! Interface Doctor missed scrolling to the second paragraph of the impression: Impression : No cholelithiasis, no bile duct dilatation. Patient was falsely reassured Cluster of with lymphStage nodes3B around renal lymphoma Patient diagnosed Hodgkins hilum 6 months later Suggest CT/PET © The Canadian Medical Protective Association cmpa-acpm.ca Interface Scrolling of Images AJR 2014;202:738 Axial © The Canadian Medical Protective Association Coronal cmpa-acpm.ca Case Interface A Discharge Summary Complaint Patient B Patient A Sexual history from another patient’s record open on the screen Mistakenly copies and pastes information into the wrong window © The Canadian Medical Protective Association cmpa-acpm.ca Cases and Lessons 4 Using automatic features © The Canadian Medical Protective Association cmpa-acpm.ca Auto Features Templates / Check Boxes © The Canadian Medical Protective Association cmpa-acpm.ca Auto Features 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 © The Canadian Medical Protective Association cmpa-acpm.ca Use Automatic Features with Care “Doctor, your notes on your physical examination don’t reflect really what happened.” “How can we believe anything you say?” © The Canadian Medical Protective Association cmpa-acpm.ca Auto Features Auto Features Paper charts With EMRs If it wasn’t charted it wasn’t done It’s charted, but was it done? © The Canadian Medical Protective Association cmpa-acpm.ca Auto features Use Automatic Features with Care • Free-text is protective © The Canadian Medical Protective Association cmpa-acpm.ca Cases and Lessons 5 Medication errors © The Canadian Medical Protective Association cmpa-acpm.ca Med errors Drop-down Menu Selection © The Canadian Medical Protective Association cmpa-acpm.ca Med errors 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 © The Canadian Medical Protective Association cmpa-acpm.ca Med errors 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 © The Canadian Medical Protective Association cmpa-acpm.ca Cases and Lessons 6 Ignoring alerts © The Canadian Medical Protective Association cmpa-acpm.ca Alerts Proper Use of Decision Aids • Clinical practice guidelines, clinical reminders • Medication contraindications and interactions • Differential diagnoses © The Canadian Medical Protective Association cmpa-acpm.ca Alerts Differential Diagnoses © The Canadian Medical Protective Association cmpa-acpm.ca Decision Aids Case Examples Alerts • TB case • Cavernous venous thrombosis © The Canadian Medical Protective Association cmpa-acpm.ca Alerts Decision Aids Alert fatigue → desensitization System assumption dismissal = acknowledgement If you dismiss a particular suggestion: consider documenting your rationale and discussing this with the patient © The Canadian Medical Protective Association cmpa-acpm.ca Other medico-legal issues… © The Canadian Medical Protective Association cmpa-acpm.ca What Is Your Best Defense? SAVED BY THE MEDICAL RECORD © The Canadian Medical Protective Association cmpa-acpm.ca Corrections and Additions “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 constitutes professional misconduct.” © The Canadian Medical Protective Association cmpa-acpm.ca 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 correctedself, etc.) • Enter the correct or missing information • Identify author © The Canadian Medical Protective Association cmpa-acpm.ca You’re Ignoring Me…. © The Canadian Medical Protective Association cmpa-acpm.ca Conclusions 1 2 3 Privacy breaches Lost records Privacy breaches Viewing Interface design 4 5 6 Using automatic features Medication errors Ignoring alerts © The Canadian Medical Protective Association cmpa-acpm.ca Conclusion • EMRs – Offer real advantages • But… – Ensure safe medical care – Safety and medico-legal issues are emerging © The Canadian Medical Protective Association cmpa-acpm.ca What will you do differently next week? © The Canadian Medical Protective Association cmpa-acpm.ca © The Canadian Medical Protective Association cmpa-acpm.ca Resources from CMPA • Data sharing principles and electronic medical record/electronic health record agreements Electronic Records Handbook, CMPA, 2014 © The Canadian Medical Protective Association cmpa-acpm.ca 1-800-267-6522 CMPA SAFE MEDICAL CARE @cmpamembers © The Canadian Medical Protective Association cmpa-acpm.ca CMPA GOOD PRACTICES GUIDE
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