EHRs Can Advance Good Medicine If Doctors Are Aware of the Risks

By David B. Troxel, MD | Published 3/2/2018 2

Doctor with computer rubbing forehead

Historically, the doctor-patient relationship has been at the heart of medical practice, with administrative tasks and record-keeping at the border.

Today, that critical balance is at risk. Nearly all hospitals and 80% of medical practices use electronic health records (EHRs), presumably to help improve access to health information and increase productivity. The problem is that none of these digital tools were designed specifically to advance the practice of good medicine.

Consider these stark statistics: Every hour doctors spend with patients, they dedicate nearly two more hours to maintaining EHRs and clerical work. Yet, even when physicians are with patients, they’re spending approximately 37% of their time interacting with EHRs or other desk work.

We are now witnessing the highest levels of physician burnout on record. Indeed, the rise of documentation demands and decrease of meaningful patient interactions has led to major physician frustrations—while making it harder for physicians to deliver quality care.

For these reasons and more, the EHR has introduced patient safety risks and unanticipated medical liability risks. According to a new study from The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, the number of EHR-related medical malpractice claims has risen over the past 10 years.


Factors behind EHR errors

For the most part, the EHR is a contributing factor in an EHR-related claim and not the primary cause. This and their low frequency (0.9% of all claims) suggest that EHRs infrequently result in adverse events of sufficient severity to develop into a malpractice claim.

When EHRs are a factor in a claim, the study showed that user factors (such as data entry errors, copy-and-paste issues, alert fatigue, and EHR conversion issues) contributed to nearly 60% of claims. As computer users, we all copy and paste. Therefore, it’s no surprise that time-pressured physicians embrace the same habits when using EHRs. In fact, the University of California San Francisco Medical Center—today considered a top five medical center in the United States—reviewed more than 23,000 of their own progress notes over an eight-month period and found that, on average, clinicians manually entered just 18% of the text in each note, while 46% was copied and 36% was imported.

System factors (such as data routing problems, EHR fragmentation, and inappropriate drop-down menu responses) contributed to 50% of claims. EHR fragmentation was the most prominent system factor, contributing to 12% of errors. This factor means that different components of a single patient encounter might not be located together in the EHR. Consequently, doctors must check in different places to find laboratory and X-ray results, histories and physicals, etc.—resulting in important information being overlooked or unidentified.


Re-claiming the doctor-patient relationship

One overwhelming response to adjusting to burdens introduced by EHRs has been the rapid growth of medical scribes. Nearly 20% of medical practices are using scribes to help untether physicians from the EHR, with many doctors citing improved efficiency and satisfaction. Yet, while scribes can offer great advantages, they can be a double-edged sword. According to a survey of hundreds of physicians from The Doctors Company, the lack of standardized training and variability in experience among scribes poses risks to data accuracy and delivery of care, which could increase liability for the patient and physician alike.

With or without scribes, lowering risk begins with each patient visit. At the beginning of each new session, doctors should inform patients of the purpose of the EHR and emphasize they are listening closely even though they might be typing during the appointment. Practices can set up treatment rooms so the patient can watch the screen and see what is being typed. It is also helpful to summarize or read the note to the patient to demonstrate that you have listened, and ask, “Do I have it right?” If the doctor is using a medical scribe to untether them from their EHR, the same principle applies.

Patients must also become their own advocates. They can ask their doctor to read back the EHR notes or review what has been written. Patients can interact with their health record online through patient portals and review their medical record as well as disease-specific educational materials and drug safety information. It is important that they communicate any errors they find as well as personal information updates to the physician.


What the future holds

As with any challenge of major proportions, progress will take time. But I’m optimistic that the EHR will evolve over the next 5 to 10 years and improve both the quality of medical care and patient safety.

Optimizing the EHR will involve:

  • Redesigning EHR workflows to reflect clinical practice workflows in hospital, clinic, and office environments. It is essential that physicians and other healthcare providers be involved in this endeavor.
  • Developing standardized diagnostic and treatment protocols.
  • Researching medical artificial intelligence (AI). This is underway and will doubtless play a significant role in future medical practice.
  • Making EHR interoperability a high priority.
  • Applying “big data” techniques to healthcare. This is underway and, like AI, will lead to new knowledge-insights that will change the practice of medicine.

Today, what I hear from The Doctors Company’s 80,000 member physicians is encouraging. Doctors are eager to “reclaim” their profession and refocus patient relationships amidst the new demands of today’s digital age. In the future, new protocols, policies, and training programs must take these small successes to a large scale.

David B. Troxel, MD


David B. Troxel, MD, is secretary of the Board of Governors and medical director of The Doctors Company. Dr. Troxel is clinical professor emeritus, School of Public Health at the University of California at Berkeley. He is past president of the American Board of Pathology and the California Society of Pathologists. He serves as chairman of The Doctors Company Foundation and as a member of the Patient Safety and Technology Committees at The Doctors Company.


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