The Beach Boys - I Get Around - Workarounds

In the recent article Targeting EHR Workarounds, the author makes the following comments: Workarounds, depending on the system and the user, might be harmless in some cases but potentially dangerous in others.

 

Whatis.com states the definition: A workaround is a method, sometimes used temporarily, for achieving a task or goal when the usual or planned method isn't working. In information technology, a workaround is often used to overcome hardware, programming, or communication problems.

The fundamental problem is that these workarounds may solve problems, but may inadvertently create hidden/unknown downstream issues.

1.      Potentially created by a non-authorized user, circumventing safeguards
2.      Putting the facility, the user, and the supervising hierarchy at liability risk
3.      Affecting data collection
4.      Missing financial credit for the documentation
5.      Missing data qualifying for “meaningful use” credit
6.      Potentially using macros with cut and paste that obscure the individuality of the encounter
7.      Potential fraud issues as to what discussions and acts were actually performed.
8.      Very important: avoiding definitive resolution of the issue. That is, by taking the workaround short-cut, and not communicating with the vendor about the problem (sometimes easier said than done), it will continue to appear for everyone.
9.      Customization may be creative but cost-prohibitive.
10.  ETC.

Many workarounds are designed to avoid alert fatigue. These may do the job most (99%) of the time but can be disastrous if key information happens to be ignored at a crucial time. See our prior blog on “Alert Fatigue”.  For example, scanning-in of relevant documents (say, a medication list) may make life apparently simpler, but if physician eyes do not see a key item (e.g. warfarin) the EH R and its decision support mechanisms will be missing critical data (so, the patient may bleed to death if sent to surgery without anticoagulant reversal).

 

Workarounds are most often created by the most innovative and intelligent clinicians among us (and the ED seems to have it share of them), trying to overcome tedious workflow issues in their E H R.  Many are guilty of discovering and using them. No names will be given. Unfortunately, however, the problems noted above can (and have) come back to haunt the provider and the facility. The best solution is find an EHR designed specifically for your area of work and engage the vendor in a continuous process of making the product more user-friendly. In that way, workarounds can quickly become a principle source of EHR and workflow improvement. “Workaround types” would enjoy listening to the Beach Boys classic –I Get Around.

8 Malpractice Dangers in Your EHR

In the 8 Malpractice Dangers in Your EHR article, the author analyzes the legal risks implicit in the use of an electronic health record.  These include:

• The healthcare provider is legally responsible for the medical record not the vendor and/or consultant even if there is the claim of a faulty product..
• Copy and pasting text.
• Lack of password control.  Sharing your password may allow certain entries and/or additions to look like provider direct input.
• Ignoring clinical decision support without careful documentation of why.
• Customizing your electronic health record without realizing you may be affecting the main data base.  Critical pieces of data must be acknowledged not just placed in the body of the note.
• Using the meaningful use criteria for payments may lead to a change in the standard of care.
• Entering incorrect information due to time pressures.
• Altering the patient-provider interaction by focusing on the computer screen, not the patient.

It is advisable any provider should read the entire article.  Most of the time, worry about these points is unnecessary.  However, the majority of lawsuits and complaints cannot be predicted in advance.  The best solution is to fully understand that every feature an electronic health record offers has some potential downside.  If aware, the provider can compensate with some explanation placed directly in the record.

The legal field is getting more sophisticated about its analysis of the electronic health record and using it to their client's advantage.  One of the huge issues is the creation of complex meandering timeline of events.  The computer documents the exact time the data was input, but does not realize when the actual events occurred.  Spending a little time on the clinical course can put large amounts of data in a logical order.