3. Health Information Technology 

Despite its great promise in reducing medical errors, the uptake of the types of health information technology which could achieve these reductions continues to be startlingly low. Fewer than 2% of hospitals and physicians are using completely integrated systems. For hospitals, that includes computerized physician order entry (CPOE), and for both hospitals and physicians, electronic medical records with all safety improvement functionalities (including clinical decision support).[1]

Even more ominously, several major electronic records installations have failed (including most recently the GE Health Care System at the University of California at San Francisco).  By its own admission, UCSF put at least part of the blame for this failure on itself, by not having sought sufficient early input from its physicians right from the start in the EMR system selection, planning and early implementation phases. Other health IT systems have actually hurt safety (e.g. an unexpected increase in mortality at a pediatrics hospital in Colorado, due to an increase in medication errors).[2] The point here is that not only are EMRs not a panacea to improve patient safety, but, implemented and/or used incorrectly or inappropriately, they may actually hurt patient outcomes and patient safety.

To dramatically increase the overall rate and appropriate and safe use of EMRs, on February 17, 2009, President Obama signed into law the American Recovery and Reinvestment Act of 2009 (ARRA or Public Law 111-5).  This act provides $34 billion of federal subsidies for hospitals and physicians to implement and “meaningfully use” electronic records between 2011 and 2015--see the Summer, 2009 issue of Risk Review on this topic for more details. Satisfying the requirements for exchanging and using electronically produced clinical data on patients at the point of care and reporting up to 25 quality measures using electronic records will qualify hospitals from October 2010 through September 2014 for up to $10.8 million, depending on size and Medicare/Medicaid mix of patients. Physicians meeting these requirements between January 2011 and December 2015 may qualify for up to $44,000 in extra Medicare reimbursement, or (not in addition to) up to $63,750 more in Medicaid reimbursement. 

The effects of this unprecedented federal support for electronic records should result in an exponential increase in their use by physicians and their hospitals over the next six years. Used appropriately to meet meaningful use requirements to qualify for all these subsidies, electronic records should also dramatically lower the rate of medical errors. 

Nevertheless, there are numerous risk management pitfalls which need to be avoided in the use of EMRs.  What these are and how to avoid them are beyond the scope of this article.  However, how to use EMRs to improve the safety and quality of care while minimizing the risks of litigation (or of defending that litigation more effectively should it still occur) is covered extensively in the Princeton Insurance Electronic Medical Records Patient Safety and Risk Management Guide—An Addition to the Physician Office Practice Toolkit (2008). 

Physicians who use EMRs in their offices appropriately should be able to improve and document the safety and quality of their care to defend themselves effectively in the event of litigation. Even more importantly, appropriate use of these safety improvement functionalities should go far in eliminating the adverse patient events resulting in litigation in the first place.

Looking Ahead

One huge area having an impact on patient safety which has not received the attention it deserves to date has been that of diagnostic errors.  These have only recently been squarely placed on the agenda for patient safety improvements in the next decade.[3] In recognition of this, the American Medical Association has “mainstreamed” the electronic diagnostic decision support system Isabel Healthcare ® to physicians nationwide starting in January 2010.  The patient safety and risk management implications of these types of systems were also discussed in the Princeton Insurance EMR Guide, previously cited.

Another equally important area concerns how to develop and use electronically generated databases to evaluate and continuously improve the quality and safety of care. To date, most quality and safety analyses (evaluating primarily the process, but not necessarily outcomes of care) have been conducted using claims databases.  However, claims databases were never designed to facilitate these types of quality and safety analyses to permit the accurate evaluation and improvement of clinical performance. The requirements to demonstrate the meaningful use of EMRs for both hospitals and physicians to qualify for up to $34 billion in federal incentive payments over the next six years has made it imperative to begin to use electronically produced information to evaluate and improve both the processes and outcomes of care. 

Over the next decade, this type of quality performance information will supplant the types of performance analyses done for the past several decades using claims-based information. The more real time ability to collect, analyze and report on this information will make it that much more important for physicians to monitor on an ongoing basis the quality and safety of their care (processes and outcomes).  This will permit them to identify potential problems before they result in litigation, or be able to defend that litigation with readily accessible proof of their adherence to best evidence practices, should litigation still occur.