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Research Letters |

The Relationship Between Electronic Health Records and Malpractice Claims FREE

Mariah A. Quinn, MD, MPH; Allyson M. Kats, MSc; Ken Kleinman, ScD; David W. Bates, MD, MSc; Steven R. Simon, MD, MPH
[+] Author Affiliations

Author Affiliations: Department of Internal Medicine, Harvard Vanguard Medical Associates (Dr Quinn), Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute (Ms Kats and Dr Kleinman), Department of Health Policy and Management, Harvard School of Public Health (Dr Bates), Section of General Internal Medicine, VA Boston Healthcare System (Dr Simon), and Division of General Internal Medicine, Brigham and Women's Hospital (Drs Quinn, Bates, and Simon), Boston, Massachusetts; and Chronic Disease Research Group of the Minneapolis Medical Research Foundation, Minneapolis, Minnesota (Ms Kats).


Arch Intern Med. 2012;172(15):1187-1189. doi:10.1001/archinternmed.2012.2371.
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Federal policies have created incentives for the adoption and meaningful use of electronic health records (EHRs).1 While EHRs enhance documentation, make visits more efficient,2 reduce medication errors, and allow providers to track and manage their entire patient population, some physicians harbor reservations about potential unintended consequences of EHRs, including a possible increased risk of adverse events.3,4 Given the potential of EHRs to reduce adverse events and health care costs, the question of whether EHRs reduce the risk of malpractice lawsuits is a logical one. Malpractice claims are associated with harm to patients and are financially costly.5 Actual and feared malpractice claims may contribute to rising health care costs owing to the practice of “defensive medicine.”5

Risk factors for medical error and resultant malpractice claims, including poor communication between providers, difficulty in accessing patient information in a timely manner, unsafe prescribing practices, and lower adherence to clinical guidelines, may be ameliorable by health information technology. The high quality and availability of proper documentation in EHRs may increase the likelihood of successful defense against malpractice claims.

Our prior work has shown a lower rate of paid claims among Massachusetts physicians using EHRs.6 That study was limited by imprecision in the temporal relationship between EHR adoption and paid malpractice claims. Available data also did not allow us to determine whether the actual rate of claims was reduced among EHR-using physicians or whether the reduction was attributable to proportionately fewer claims leading to payment. Therefore, we undertook this follow-up study.

We merged closed-claims data from a major malpractice insurer in Massachusetts for physicians covered from 1995 to 2007 with data from surveys administered to a random sample of Massachusetts physicians in 2005 and 2007 (response rates, 71% and 79%, respectively), comprising a final sample of 275 and 189 physicians, respectively. Survey methods are described elsewhere.7

Because physicians in the sample were insured for different durations and used EHRs for variable amounts of time, the number of insured years was calculated for each physician before and after EHR adoption. We used Poisson regression to determine whether EHR use was associated with malpractice claims, modeling the rate of malpractice claims per year in periods with and without EHRs and adjusting for clustering by physician. We used the generalized linear mixed models version of Poisson regression to account for correlation between periods.8

Of the 189 physicians surveyed in both 2005 and 2007, a total of 27 (14.3%) were named in at least 1 malpractice claim. Overall, 33 of the 275 physicians from multiple surgical and medical specialties who responded in 2005 and/or 2007 incurred a total of 51 unique claims (Table); 49 of these claims were related to events occurring before EHR adoption, and 2 were related to events occurring after EHR adoption. The use of EHRs was associated with a lower rate of malpractice claims, with an estimated relative risk of 0.16 (95% CI, 0.04-0.71).

Table Graphic Jump LocationTable. Number of Malpractice Claims by Specialty Before and After EHRa

We found that the rate of malpractice claims when EHRs were used was about one-sixth the rate when EHRs were not used. This study adds to the literature suggesting that EHRs have the potential to improve patient safety and supports the conclusions of our prior work,6 which showed a lower risk of paid claims among physicians using EHRs. By examining all closed claims, rather than only those for which a payment was made, our findings suggest that a reduction in errors is likely responsible for at least a component of this association, since the absolute rate of claims was lower post-EHR adoption.

Unmeasured factors may, in part, account for the apparent 6-fold reduction in malpractice claims attributed to EHRs. For example, physicians who were early adopters of EHRs may exhibit practice patterns that make them less likely to have malpractice claims, independent of EHR adoption; these early adopters contribute a disproportionate amount of time in our analyses, favoring an effect of EHRs on reducing malpractice claims. Furthermore, other interventions may have occurred concurrent with EHR implementation that could account for some of the observed reduction of malpractice claims attributed to EHRs.

Our study featured a long observation period, during which many of the practices adopted EHRs, enabling a pre-post assessment. Generalizability may be limited, as participants included only those physicians in Massachusetts who were affiliated with Harvard Medical School, Boston, and who were covered by 1 malpractice insurer (CRICO/RMF [Controlled Risk Insurance Company/Risk Management Foundation]). The short period after EHR adoption may have limited our ability to ascertain whether claims that are more delayed (eg, missed or delayed diagnoses) are affected by the use of EHRs.

While this study includes only a small number of post-EHR claims, it suggests that implementation of EHRs may reduce malpractice claims and, at the least, appears not to increase claims as providers adapt to using EHRs. The reduction in claims seen in this study among physicians who adopted EHRs lends support to the push for widespread implementation of health information technology.

Correspondence: Dr Simon, Section of General Internal Medicine, VA Boston Healthcare System, 150 S Huntington Ave, Bldg 9 (152G), Boston, MA 02130 (steven.simon2@va.gov).

Published Online: June 25, 2012. doi:10.1001/archinternmed.2012.2371

Author Contributions:Study concept and design: Quinn, Bates, and Simon. Acquisition of data: Quinn, Bates, and Simon. Analysis and interpretation of data: Quinn, Kats, Kleinman, and Simon. Drafting of the manuscript: Quinn. Critical revision of the manuscript for important intellectual content: Quinn, Kats, Kleinman, Bates, and Simon. Statistical analysis: Quinn, Kats, and Kleinman. Obtained funding: Bates. Administrative, technical, and material support: Bates and Simon. Study supervision: Quinn, Bates, and Simon.

Financial Disclosure: None reported.

Funding/Support: This work was supported by grant number 1UC1HS015397 from the Agency for Healthcare Research and Quality, by the Massachusetts e-Health Collaborative, and by a faculty grant from the Harvard Pilgrim Health Care Foundation. Dr Quinn was supported by an Institutional National Research Service Award (5 T32 HP11001-19).

Role of the Sponsors: The Agency for Healthcare Research and Quality, the Massachusetts e-Health Collaborative, and the Harvard Pilgrim Healthcare Foundation had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the Harvard Pilgrim Healthcare Foundation, the Agency for Healthcare Research and Quality, or the Massachusetts e-Health Collaborative.

Additional Contributions: CRICO/RMF of the Harvard Medical Institutions provided data and assistance in conducting this research, and Megan McNeill provided administrative assistance.

 Electronic health records and meaningful use. US Department of Health and Human Services Web site. http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2. Accessed March 12, 2012
Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review.  J Am Med Inform Assoc. 2005;12(5):505-516
PubMed   |  Link to Article
Love JS, Wright A, Simon SR,  et al.  Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use [published online December 23,2011]?  J Am Med Inform Assoc
PubMed  |  Link to Article
Koppel R, Metlay JP, Cohen A,  et al.  Role of computerized physician order entry systems in facilitating medication errors.  JAMA. 2005;293(10):1197-1203
PubMed   |  Link to Article
Studdert DM, Mello MM, Gawande AA,  et al.  Claims, errors, and compensation payments in medical malpractice litigation.  N Engl J Med. 2006;354(19):2024-2033
PubMed   |  Link to Article
Virapongse A, Bates DW, Shi P,  et al.  Electronic health records and malpractice claims in office practice.  Arch Intern Med. 2008;168(21):2362-2367
PubMed   |  Link to Article
Simon SR, Kaushal R, Cleary PD,  et al.  Physicians and electronic health records: a statewide survey.  Arch Intern Med. 2007;167(5):507-512
PubMed   |  Link to Article
Breslow NE, Clayton DG. Approximate inference in generalized linear mixed models.  J Am Stat Assoc. 1993;88:9-25
Link to Article

Figures

Tables

Table Graphic Jump LocationTable. Number of Malpractice Claims by Specialty Before and After EHRa

References

 Electronic health records and meaningful use. US Department of Health and Human Services Web site. http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2. Accessed March 12, 2012
Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review.  J Am Med Inform Assoc. 2005;12(5):505-516
PubMed   |  Link to Article
Love JS, Wright A, Simon SR,  et al.  Are physicians' perceptions of healthcare quality and practice satisfaction affected by errors associated with electronic health record use [published online December 23,2011]?  J Am Med Inform Assoc
PubMed  |  Link to Article
Koppel R, Metlay JP, Cohen A,  et al.  Role of computerized physician order entry systems in facilitating medication errors.  JAMA. 2005;293(10):1197-1203
PubMed   |  Link to Article
Studdert DM, Mello MM, Gawande AA,  et al.  Claims, errors, and compensation payments in medical malpractice litigation.  N Engl J Med. 2006;354(19):2024-2033
PubMed   |  Link to Article
Virapongse A, Bates DW, Shi P,  et al.  Electronic health records and malpractice claims in office practice.  Arch Intern Med. 2008;168(21):2362-2367
PubMed   |  Link to Article
Simon SR, Kaushal R, Cleary PD,  et al.  Physicians and electronic health records: a statewide survey.  Arch Intern Med. 2007;167(5):507-512
PubMed   |  Link to Article
Breslow NE, Clayton DG. Approximate inference in generalized linear mixed models.  J Am Stat Assoc. 1993;88:9-25
Link to Article

Correspondence

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Concerns Regarding the Relationship between Electronic Health Records and Malpractice Claims
Posted on October 26, 2012
Frederick J. White III, MD, FACC, FCCP, and William P. Coleman III, MD, FAAD
Louisiana Medical Mutual Insurance Company
Conflict of Interest: None Declared

We read with interest the article by Quinn MA, et al., which demonstrates a decrease in the rate of medical malpractice claims after adoption of an electronic health records system (EHR).(1) The authors’ hypotheses have been developed in a series of four publications, published between 2007 and 2012.(1-4) In a 2007 study, the authors found several static and dynamic factors to be significant covariates to EHR adoption rates.(3) In the 2008 survey, an apparently significant difference in numbers of paid malpractice claims among EHR adopters and non-adopters (and favorable to EHR adoption) disappeared when logistic regression for covariates was applied.(4) 

The current study, dichotomizing malpractice claims rates of individual physicians before and after EHR adoption, controls for static covariates by design. But this design does not control for known dynamic covariates, including several identified covariates that were not tested in the authors’ prior studies.(5) The causation of the reported serial differences in malpractice claims rates before and after EHR adoption is thus questionable. For example, a late career EHR adopter may also be decreasing the number of patient encounters, increasing time spent in patient communication, and intensifying risk management activities. This physician may experience a decline in the rate of malpractice claims due to factors contemporaneous to but completely independent of EHR adoption. 

The current study also does not account for the larger secular downward trend in malpractice claims for the period under study. A respected national accounting company has reported data indicating that the malpractice paid claims rate nationwide declined by 25 to 30% in the period from 1995 to 2007.(6) Not to account for this trend or for the known dynamic covariates in the time-dependent analysis applied to the study data makes the current study difficult to interpret. It is also of note that none of the actual data on claims rates is included in this report. The only specific data are raw claims counts in the Table, which have no time period for duration of exposure. 

As we struggle to determine the value of EHRs and whether their adoption aggravates or improves the rates of medical malpractice claims, we need transparent and statistically accurate studies which provide readers with reliable information. 

1. Quinn MA, et al. The relationship between electronic health records and malpractice claims. Arch Intern Med 172(15):1187-1189

2. Simon SR, et al. Correlates of electronic health record adoption in office practices: A state survey. J Am Med Inform Assoc 2007; 14(1):110-117. 

3. Simon SR, et al. Physicians and electronic health records: A statewide survey. Arch Intern Med 2007; 167(5):507-512. 

4. Virapongse A, et al. Electronic health records and malpractice claims in office practice. Arch Intern Med 2008; 168(21):2362-2367.

5. Gibbons RD, et al. A random-effects probit model for predicting medical malpractice claims. J Amer Statistical Assoc 1994; 89: 760-767.

6. KPMG LLP, Trends in physician liability claims frequency, September 15, 2010, http://www.casact.org/education/clrs/2010/handouts/HC2-Trends.pdf.

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