EHR Event of the Month: "Written in Stone"
- Michael Victoroff, M.D., Editor-in-Chief
From a nurse who requests anonymity:
I’m still shaking about what almost happened. I work at a large facility and have no influence on EMR policy. I prevented a bad error the other day. But, this happens all the time and I’m sure we have harmed patients because THERE’S NO WAY TO CORRECT NOTES THAT HAVE MISTAKES! A progress note got entered under the wrong patient name. It was for a patient scheduled to have an IUD, but it got put in the chart of a non-English speaking woman who was there for her initial OB visit. We set up for the IUD, and the doctor read the note and got ready. But, something seemed wrong and I scrolled down and saw another note that said, “Disregard note xx/xx/xx, wrong chart.” There was actually a little footnote at the bottom of the first note: “Amended xx/xx/xx.” But, it was easy to miss, and the erroneous note looked completely fine.
The system doesn’t let us edit notes, no matter what’s wrong with them. It’s usually a date, or medication, or left/right side, or some typo that just gets in there and you don’t want it to show up forever. It could say “HIV positive” by mistake. You can make another note that says, “THE OTHER NOTE IS WRONG!” but it shows up in a different place, or off the screen. And it doesn’t change the first note – or the diagnosis on the problem list, or the billing code, or the medication list, which you can change but not delete. You can’t enter a diagnosis “Not HIV positive, just kidding.” All you can do is make it “inactive.” You can’t erase it. This would be so easy to fix, but they say it’s illegal to change a note no matter how stupid or dangerous it is. I would be scared to be a patient in my own clinic, because you can’t trust any note unless you read them all.
Change we can believe in
Ah, where to begin? On paper, there’s a well-accepted procedure for altering a record: You scratch through the erroneous material (taking care to leave it legible). You make your correction in a way that’s obvious. You sign and date the amendment so everyone can tell exactly what you did. Simple on paper – but impossible for many EHRs.
Record “alteration” is only a problem if it’s deceptive or fraudulent. Properly and transparently done, a correction protects subsequent readers from relying on a faulty document while avoiding any implication of mischief. Everyone wins. But, many EHRs have an imbalance between the goal of data integrity, and the goal of delivering clinical information – swiftly, easily, accurately. This shouldn’t be rocket science, but rocket scientists don’t build many EHRs.
Creating superfluous, extra notes to explain mistakes is a cumbersome solution and invites error. Popular word processors have a feature to “track changes.” This captures additions, deletions, relocations, etc., with timestamps and author IDs. The marked-up version is handy for editors (and lawyers), but once edits are accepted, the final version is readable. As a clinician, I don’t care how many corrections went into the previous provider’s progress note. I don’t want to see the director’s cut of “The Making Of The Note.” I just want a clean record, as true as it can be. Don’t put more barriers between me and my data – the job is tough enough already. Unfortunately, some EHRs are designed with the misunderstanding that protecting records from alteration trumps usability.
Maybe our distorted tort system makes the secondary risk of evidence tampering more important than the primary risk of killing patients. But, there’s no technical reason for a zero-sum solution. I.T. systems can deliver accurate, usable documents at the point of care while unobtrusively capturing forensic metadata for the rare occasions when they need to be produced. Come on, designers!
The top priority of an EHR system must be patient safety. Other agendas, please step to the rear.
To report a suspected EHR Safety Event, visit www.EHRevent.org.
AHRQ EHR Guide
The Agency for Healthcare Research and Quality (AHRQ) has recently published an online Guide to Reducing Unintended Consequences of Electronic Health Records. This resource is designed to help physicians and organizations anticipate, avoid, and address problems that can occur when implementing and using an EHR.
The Guide is based on published literature and guidelines, research by the authors and interviews with organizations that have implemented EHRs. It represents a compilation of best practices. However, the authors caution that “[T]his area of research is still in its infancy.”
The RAND Corporation prepared the Guide for AHRQ under contract HHSA290200600017I, Task Order #5. The authors of the Guide are Spencer S. Jones, Ross Koppel, M. Susan Ridgely, Ted E. Palen, Shinyi Wu, and Michael I. Harrison.
For more information on the AHRQ or the AHRQ Guide, please visit www.AHRQ.gov.
A number of upcoming events are focused on the safe adoption and use of Electronic Health Records:
• National Forum on Quality Improvement in Health Care
(December 4-7, 2011)
• HIMSS Annual Conference & Exhibition
(Feb. 20-24, 2012)
In addition, the The American Health Information Management Association (AHIMA) recognizes Health Information & Technology Week from November 6-12. For more information, please visit the AHIMA web site