Issue 31 / 13 August 2012

The public debate in the lead up to the launch of the Personally Controlled Electronic Health Record (PCEHR) has missed a crucial point ― the quality of doctors’ medical records will always be critical to the delivery of high-quality and safe patient care.

Clearly a key element likely to impact on the success, or otherwise, of the PCEHR is the quality of the health summaries uploaded by the nominated health practitioner (usually the GP).

Any risks to patients (and medicolegal risks to doctors) resulting from interaction with the PCEHR will emerge slowly (in line with the expected uptake) so the extent of the risk to doctors is difficult to predict so early in the rollout.

As a GP and a risk adviser, I am often asked about how doctors can reduce their medicolegal risk when it comes to electronic health records. A common question is whether electronic health records afford a doctor greater medicolegal protection than paper records.

The answer is “yes” and “no”.

While well considered and implemented e-record systems can improve the safety and quality of clinical care, in the absence of good design, implementation and training these systems can also result in risks to patients.

A significant big picture problem, articulated in an MJA editorial in April this year, is a lack of national e-health clinical safety governance. This needs to be rectified, given, as the authors point out, e-health in Australia is neither regulated nor monitored at this time.

From a medicolegal point of view, it is important to consider the risks and benefits when making the decision to use e-health records. It is a decision that many of our specialist colleagues have yet to make.

The benefits include the fact that e-health records offer a legible, reproducible health record that can assist in the legal defence of a claim brought against a doctor.

However, some of the risks relate to the differences between paper and electronic notes, in the way doctors enter and interrogate data.

Electronic notes were developed to create efficiencies rather than specifically focusing on patient safety. For example, the structure of electronic records can make reading back through the notes more difficult, which could encourage doctors to manage problems in isolation with little or no reference to prior attendances.

Other risks relate to the quality and quantity of data recorded by the doctor. Many doctors have limited keyboard skills and are time poor. The recognised shortcuts used in the written records such as arrows and diagrams do not easily translate into the typewritten record. To overcome the problem, doctors may use macros or shortcut keys.

Of itself, the use of such tools is not a problem unless the entry is too general to be useful or is repeated frequently without proper consideration of whether it is applicable in the particular patient’s circumstance.

Likewise, several software packages allow for tick-box entry for history and examination. Again, care is required to ensure that the record reflects the actual history and examination that have been undertaken.

For example, to enter that femoral pulses are normal when they have not been examined would render the record meaningless both clinically and in defending a claim. It is possible that this situation could also render the records false and inaccurate.

Many medical negligence claims arise when doctors fail to diagnose and follow up, or miss key results. Many practices do not have policies to manage their electronic results consistently. If a doctor is away from the practice, results might not be reviewed.

In addition, recall and follow-up mechanisms alter with electronic records. Electronic systems have the potential to create efficiencies in linking abnormal patient results with recall systems and in tracking referrals and appointments, but processes need to be developed by the entire practice to ensure that this occurs in a consistent manner.

The good news is that there are a number of strategies doctors can use to mitigate their medical record-related medicolegal risks. Good examples include ensuring the data used are clean (i.e. current and accurate) and that appropriate backup processes are always in place.

Voice recognition software has been proposed as a useful alternative for doctors with poor keyboard skills but it is not without problems, and practice and training are required to use it effectively.

In general, education is important for minimising risk. Often, practitioners are not familiar with how to use the software effectively. It is often introduced into a group practice with minimal training or appropriate policy development to ensure safety.

It is up to governments, hopefully well advised by doctors, to grapple with these important broader issues around e-health record standards, but it is up to individual practices and practitioners to decide what type of medical records they choose to use and how to use those records safely and effectively to provide good patient care.

Dr Penny Browne is a GP and medicolegal adviser with Avant

Posted 13 August 2012

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