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Physician Diligence Needed Even with EMR Systems

Notwithstanding the usual suspects that hinder electronic medical record implementation — initial costs, interoperability problems, training burdens, and altered physician-patient dynamics — there’s also the risk of a pure system malfunction. In a malpractice suit after an admitted malfunction, a physician’s actions will still be scrutinized.

Dr. PC had been the primary care physician to her 80-year-old patient for more than a decade and in the years leading up to the event, assessed her with hypotension, hypothyroidism, adrenal insufficiency, kidney disease causing anemia, Addison’s Disease, bipolar affective disorder, and GERD. The patient was on a regimen of 14 different medications to manage her complicated medical conditions.

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Some seven weeks following the patient’s last visit, electronic records showed prescriptions ordered for her by Dr. PC. Those separate electronic prescriptions showed a lower than usual prescription for the patient’s thyroid medication and a new prescription for Glipizide. Both electronic prescriptions correctly listed the patient’s lengthy “other meds.”

Two weeks later, the patient was admitted to the emergency room with an altered mental state. A head CT showed no pathology, but her fasting blood glucose was 22 (normal 70-110).

The patient was diagnosed with acute encephalopathy stemming from the Glipizide prescription. When the ER physician called Dr. PC about the Glipizide, Dr. PC told her that the patient was not diabetic and that she did not prescribe Glipizide. The ER physician then told Dr. PC that the patient had a prescription bottle for Glipizide with Dr. PC listed as the prescribing MD.

After a course of electrolytes and medication over four days at the hospital, the patient spent another two weeks at a nursing facility before going home in good condition.

Following the telephone call with the ER physician, Dr. PC reviewed her patient’s chart and noted for the first time that she had electronically signed an order for Glipizide. She immediately cancelled the prescription and discussed the event with her partners, who told her they had noticed instances at around the same time of patients receiving medication prescribed for other patients.

Dr. PC’s medical group contacted the EMR provider, which responded with a generic message several weeks after the incident stating, “a few clients have recently reported that documents are being moved to another chart upon signing. We investigated this issue today . . . and we found this may happen to any type of document that is signed from the mailbox; i.e., the current document may be misfiled into the previous patient’s chart right after being signed.

Please watch for any misfiled documents in patients’ charts.” The letter recommended signing from an open chart as work-around pending a software update.

When Dr. PC was sued by the patient for medical malpractice, her defense attorney filed a cross- complaint against the EMR provider. The EMR system then cross-complained against Dr. PC, alleging that the Glipizide prescription was Dr. PC’s own error.

Undercutting a defense that would have Dr. PC point to the EMR provider as the sole responsible party for the plaintiff’s (fortunately) short-lived injuries was Dr. PC’s own electronic sign-off on the actual Glipizide prescription and the lack of documentation in the patient’s file regarding contacting the EMR firm.

In its cross-complaint against Dr. PC, the company mentioned only briefly the EMR’s patient- tracking features and instead focused heavily on its prescription-processing functions. The company alleged that Dr. PC entered the necessary information and “clicked the requisite tabs and icons” for the software to initiate her electronic signature for the prescription. Again focusing on the prescription component of the EMR system, the company alleged there was “no bug or anomaly in the software, and that the software did not issue any prescriptions on its own accord."

The case resolved informally.

EMR systems are, in the end, human systems, and as such, physicians need to maintain all of the safeguards they would normally employ to guard against patient harm when using them.


Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to