Whether you have been practicing for 15 years or you have just started practicing, one of the biggest threats to your long-term success and well-being over the course of your career is the ability to practice in a manner that will avoid malpractice litigation.There are 3 major areas of medical record breakdown that lead to malpractice litigation. They include the following.
Failure to Follow-Up
All clinicians suffer from the same anxieties. Decreasing reimbursement means a necessary increase in patient load. With increasing patient load comes a river of information that is never ceasing. Laboratory orders, radiology orders, biopsies, diagnostic procedures, consultations both incoming and outgoing. We are all appropriately concerned about the information that we trigger. However, the resulting information often does not get brought to our attention. That abnormal laboratory, the abnormal radiology, the abnormal biopsy. It sits on a piece of paper somewhere. Unseen and unverified. The patient comes in 6 months later and says, “What did my biopsy show?” You don’t have it in the chart. You ask the nurse to dig it up, and when she brings it to you it shows adenocarcinoma. The only winners here are the malpractice attorneys..
How might you have avoided this?
With a typical EHR system it is impossible to avoid, and it’s just a question of when it’s going to happen. There is simply too much information going out and coming back, and the problem is that it is impossible for any office to keep track of such a volume of information.
Novoclinical is Not Typical.
The system design was built to obey Issac Newton’s third law of motion. Every action creates a reaction, or at least an expectation of reaction. Every order on every patient triggers a timed event and expectation of return. The amount of time can be personalized. Most labs and radiology orders return through the system directly and are automatically advanced to the physician duty sheet. Furthermore, if a laboratory, radiology or consultation report does not return by the allotted time, it will notify the physician and the nurse immediately so that the result can be sought out and collated with the expectation. This makes it possible to achieve 100% tracking of results with standard compliance. Of course it means that you have to order within the system and receive feedback that the test was ordered. This takes only moments with each case, and at the end of the day, everybody goes home secure in the knowledge that all information will be handled appropriately. The only losers are the malpractice attorneys.
After you have seen the system in action this will seem so obvious that it will be impossible to imagine life without it.
Inadequate Documentation
The other way that the system protects you is through free speech. Doctors have been taught that the best way to work is with drop downs menus, but any malpractice attorney will tell you that free form speech is a much better defense against malpractice claims than a drop down menu selection. When using drop downs, it is legally advisable to provide a lot of typed explanation along with that drop down blurb. With our system you can even just dictate the entire note.
It is okay to use drop down menus . We have them. We simply don’t recommend using them more than you need to. An old internist, when training his proteges, told them to never put anything on the chart that they wouldn’t feel comfortable explaining on a witness stand. There is nothing better on a medical record than explicit references to the patient’s own explanation as closely as possible to how they said it. That’s why NovoClinical allows physicians to dictate their notes with the patient in the room. Patients can even listen to the dictation, and actively correct a physician if they say something wrong. Ultimately, they understand that you understand, and you are always talking about the same thing. With Novoclinical this is so integral, and referred to as, “over the shoulder technology.” Your primary focus is, of course, the conversation with the patient, and NovoClinical allows charting to become incidental to the visit, but also an encapsulation of the spirit of that conversation. This can include, if desired, an audio recording of the visit (with patient permission) that is stored in the database.
Language Barrier
The final place where practice breaks down into malpractice occurs in translational errors. NovoClinical has a built-in translation module whereby the physician can speak in English into the system and then touch their screen for immediate translation into a multitude of languages. We are working on implementing a conversational system that will allow immediate translation between English and Spanish for the physician and patient. Real time.
Physicians are creatures of habit. Even if they dislike their current system, they are reluctant to change (even if that extant system is ruining their life, practice, and endangering them).
Progress requires change, and change is often painful. But remember, if you have to eat something bad there is no point in nibbling. Ultimately, the pain of change will be far outweighed by peace of mind.