Oversight in Electronic Health Record Causes a Delay in Ovarian Cancer Diagnosis
Laura M. Cascella, MA
Electronic health records (EHRs) have transformed the ways in which healthcare providers work and communicate. These systems have been both extolled and criticized over the past decade as their use in hospitals, healthcare practices, and other healthcare facilities has skyrocketed.
Like many advanced technologies, EHR systems represent a complex dichotomy — they can be both beneficial and problematic, as illustrated in this case study from the Pacific Northwest.
Case Details
The patient was a female in her early fifties with a strong family history of breast cancer. Based on the patient’s family history, her gynecologist, Dr. B, ordered BRCA1 and BRCA2 analysis. The patient’s results were received from the laboratory and scanned into the OB/GYN practice’s EHR system.
The top portion of the report indicated a positive finding for a potentially harmful mutation. This information was included in large, capitalized, bold lettering. In the lower portion of the report, however, a box with small print indicated no mutations were detected in the BRCA1 (5-site rearrangement panel) and BRCA2 sequencing. Dr. B believes that when he reviewed the report in the EHR, he scrolled down too far initially and missed seeing the top of the report.
Eighteen months later, the patient was diagnosed with Stage III ovarian cancer. The patient subsequently filed a lawsuit against Dr. B. Experts who testified in the case believed that the cancer was not present at the time of BRCA testing. They felt that if the patient had undergone bilateral salpingo-oophorectomy at that time, her risk of primary peritoneal cancer would have been around 1 percent. Ultimately, the case was settled against Dr. B, with both payment and defense costs in the high range.
Discussion
EHR systems have become commonplace in healthcare organizations. Although doctors and other healthcare professionals have seen the benefits of these systems, they also have noted numerous challenges with EHR functions, capabilities, and overall effect. Similarly, EHRs have presented new issues in relation to malpractice.
A PIAA survey found that 53 percent of member companies had EHR-related malpractice litigation.1 Major contributing factors in this litigation included problems with documentation, system functionality, metadata, record format, vendor support, and more.
In this particular case, a simple oversight of critical information on a report scanned into the OB/GYN practice’s EHR system led to a diagnostic error and a poor patient outcome. Of note, the OB/GYN practice in this case was implementing a new EHR system at the time that this error occurred. Dr. B’s lack of familiarity with the system may have contributed to him missing the critical information on the lab results.
The process of implementing or upgrading an EHR system is vulnerable to errors because of the changes that occur, such as transfer of data, workflow modifications, and new interfaces. Implementing or upgrading an EHR system requires thorough research, careful planning, and ongoing assessment and adjustment once the system is in place.
To minimize the risks associated with implementation, healthcare practices should develop clear policies for transitioning data between systems and for reconciling information, so as not to misplace data or overlook critical health information. Further, careful evaluation and an open dialogue with healthcare providers and staff about workflow processes may help identify potential issues early and facilitate the development of effective strategies.
Additional steps that healthcare practices can take to reduce the risk of errors, improve patient safety, and reduce liability exposure when implementing an EHR system include:
- Asking healthcare providers and staff members who will be using the EHR system to participate in initial research and planning activities related to EHR acquisition and implementation.
- Developing a protocol for how records and reports should be displayed in the EHR system, as well as expectations for thorough review of patient records and test/consultative reports.
- Seeking input from providers and staff about developing policies and workflow procedures that align with the new system.
- Ensuring that the new EHR system supports the healthcare practice’s patient tracking protocols, and reviewing whether alerts or other features are available to help facilitate communication of critical findings.
- Supporting healthcare providers and staff throughout the implementation phase by including them in the decision-making process, maintaining transparent communication, and establishing firm expectations related to EHR use.
- Providing training and education during implementation and after to help staff (a) acclimate to the new system, (b) recognize potential process or system problems, and (c) work toward reasonable solutions.
Conclusion
Despite mixed reception, EHRs continue to represent the modern approach to documentation of patient care. These systems will be around for the foreseeable future and will continue to evolve as healthcare communication and technology change.
Like all types of technology, EHR systems aren’t without risk. Changes in workflow, poor understanding of the system and its capabilities, user errors, and lack of defined protocols can all lead to process breakdowns and errors.
Awareness of the potential risks that EHRs present can help healthcare providers and staff proactively counter them through ongoing staff training, workflow evaluation, and development of comprehensive policies and procedures.
