emerging healthcare technology system

ORIGINAL INVESTIGATION

Electronic Health Records and Malpractice Claims in Office Practice Anunta Virapongse, MD, MPH; David W. Bates, MD, MSc; Ping Shi, MA; Chelsea A. Jenter, MPH; Lynn A. Volk, MHS; Ken Kleinman, ScD; Luke Sato, MD; Steven R. Simon, MD, MPH

Background: Electronic health records (EHRs) may im- prove patient safety and health care quality, but the re- lationship between EHR adoption and settled malprac- tice claims is unknown.

Methods: Between June 1, 2005, and November 30, 2005, we surveyed a random sample of 1884 physicians in Mas- sachusetts to assess availability and use of EHR func- tions, predictors of use, and perceptions of medical prac- tice. Information on paid malpractice claims was accessed on the Massachusetts Board of Registration in Medicine (BRM) Web site in April 2007. We used logistic regres- sion to assess the relationship between the adoption and use of EHRs and paid malpractice claims.

Results: The survey response rate was 71.4% (1345 of 1884). Among 1140 respondents with data on the pres- ence of EHR and available BRM records, 379 (33.2%) had EHRs. A total of 6.1% of physicians with an EHR had a

history of a paid malpractice claim compared with 10.8% of physicians without EHRs (unadjusted odds ratio, 0.54; 95% confidence interval, 0.33-0.86; P=.01). In logistic re- gression analysis controlling for sex, race, year of medical school graduation, specialty, and practice size, the rela- tionshipbetweenEHRadoptionandpaidmalpracticesettle- ments was of smaller magnitude and no longer statisti- cally significant (adjusted odds ratio, 0.69; 95% confidence interval, 0.40-1.20; P=.18). Among EHR adopters, 5.7% of physicians identified as “high users” of EHR had paid malpractice claims compared with 12.1% of “low users” (P=.14).

Conclusions: Although the results of this study are in- conclusive, physicians with EHRs appear less likely to have paid malpractice claims. Confirmatory studies are needed before these results can have policy implications.

Arch Intern Med. 2008;168(21):2362-2367

I N THE PAST 10 YEARS, HEALTH IN-formation technology (HIT) hasemerged as an essential compo-nent of a transformed health caresystemthat focusesonsafety,qual- ity, and efficiency.1,2 Although results of some studies have been equivocal,3,4 the po- tential impact of HIT on the safe practice of medicine seems increasingly compel- ling: if used actively by caregivers, studies indicate that HIT can reduce adverse drug events and improve physician perfor- mance in areas such as diagnosis, preven- tive care, disease management, drug dos- ing, and drug management.5 , 6 One component of HIT in particular, elec- tronic health records (EHRs), has been tar- geted by policymakers as an essential tool for ensuring the secure availability of pa- tient health records across health care en- tities and for reducing health care spend- ing.7 Many clinicians have also recognized the benefits of implementing an EHR de- spite the large initial capital expenditure. Research indicates that EHRs can improve

documentation, enhance the efficiency of clinic visits,8 minimize medication errors, and enable clinicians to perform popula- tion surveillance and monitoring.2,9 As a re- sult, EHRs are being increasingly adopted by caregivers seeking to improve the qual- ity of patient care.10

The potential for EHRs to prevent ad- verse events and reduce health care costs has also created interest in whether use of EHRs reduces the risk of malpractice law- suits. The Joint Commission on Accredi- tation of Healthcare Organizations has sug- gested that HIT can address factors that have proved to be risk points for error and subsequent malpractice suits by patients, such as communication among care- givers, availability of patient informa- tion, medication prescribing, and adher- ence to clinical guidelines.11 One study12

that involved 307 closed malpractice cases claiming medical negligence found that more than half of the cases were due to di- agnostic errors that harmed patients. Most of these errors occurred because of fail-

Author Affiliations: Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital (Drs Virapongse, Bates, and Sato and Ms Jenter), Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care (Ms Shi and Drs Kleinman and Simon), Boston, Partners Health Care, Wellesley (Dr Bates and Ms Volk), Harvard Risk Management Foundation, Cambridge (Dr Sato), Massachusetts.

(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 21), NOV 24, 2008 WWW.ARCHINTERNMED.COM 2362

©2008 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ on 05/30/2020

ure to order diagnostic tests or lack of a follow-up plan. Because EHRs and HIT seem to mitigate reliance on cog- nitive factors through clinical decision support and avoid- ance of errors of omission, diagnostic errors may in turn decrease with implementation of such systems. Further- more, electronic documentation tends to be superior to the paper record in legibility and completeness. Since many lawsuits hinge on the presentation of proper docu- mentation to the court, a thorough and accurate medi- cal record would likely make lawsuits easier to defend for physicians.13 Many malpractice claims also base their allegations on the failure to adhere to the standard of care. With the inclusion of decision support into an EHR, phy- sicians can be presented with the relevant guidelines from the onset of ordering treatment and may be more likely to adhere to them.

In addition, malpractice claims due to medical errors constitute the bulk of malpractice claim payouts and ad- ministrative costs.14 Of all malpractice claims, 83% show no evidence of negligence, and most of these claims with- out injury are uncompensated or account for a small frac- tion of overall malpractice costs.14,15 Thus, if medical er- rors were minimized through HIT, significant health care savings would occur through a reduction in tort- associated costs. Conversely, some studies16,17 have shown that HIT has the potential to increase adverse events at- tributable to information errors and human-machine in- terface flaws. Although these reports primarily focus on computerized physician order entry systems in hospital settings, the fact remains that adoption of any HIT is not without risk, and unintended consequences may create a new realm of litigation issues.

Despite a considerable body of evidence indicating that HIT can prevent medical errors, little is known about the relationship between EHR adoption in the office prac- tice setting and medical malpractice claims. Few data are available to evaluate the association between use level of EHR functions and the prevalence of malpractice claims. In the inpatient setting, use of computerized physician order entry was correlated with a lower frequency of medi- cation-related malpractice claims,18 but the frequency of these claims is low enough to make such analyses diffi- cult. To assess whether EHR use was associated with fewer paid malpractice claims, we linked survey data about EHR adoption and use to physician profile data from the Mas- sachusetts Board of Registration in Medicine (BRM).

METHODS

The sampling methods, survey questionnaire development, and survey administration have been published elsewhere19,20 and are described briefly herein.

SAMPLE

Using a database from a private vendor (Folio Associates, Hy- annis, Massachusetts) and information from the BRM,21 we iden- tified the population of practicing physicians in Massachu- setts in 2005. After excluding physicians who were residents in training, retired, or without direct patient-care responsibili- ties, the total population of physicians was 20 227. These phy- sicians practiced in 6174 unique practice sites in Massachu-

setts. Of these practices, a stratified random sample of 1921 practices was obtained, and 1 physician from each practice was randomly selected for the survey. After excluding practices that had closed, the final sample size was 1884 physicians.

SURVEY

We administered a survey by mail between June 1, 2005, and November 30, 2005, to physicians in office practice in Massa- chusetts. The 8-page questionnaire was based on a systematic review of the literature regarding barriers to EHR adoption and ascertained physician and practice characteristics, adoption of EHRs and other HIT, and use of EHR functions. Initially, the sur- vey was sent via express mail with a $20 cash honorarium. Two subsequent mailings to nonresponders were sent without remu- neration. Between mailings, multiple telephone contacts were at- tempted to remind physicians to complete the survey.

The survey ascertained physicians’ personal demographic and practice characteristics and their use of HIT, including EHRs. Physicians reported their age; race, which we dichotomized as white vs other; year of medical school graduation; and num- ber of physicians in their practice. We determined each phy- sician’s specialty from the database from which we drew the survey sample.

MALPRACTICE CLAIMS DATA…