Learning objectives: Electronic health records (EHR) can prevent several serious errors in diagnosis by improving access to vital patient information.
Case information: A 63 year old female with documented history of hypothyroidism presented for follow up. Laboratory evaluation revealed suppressed thyroid stimulating hormone (TSH). Previously, she had been maintained on levothyroxine for five years without dose adjustment. Since the system had just transitioned to EHR, her paper chart was reviewed. Five years prior, she was in the same clinic session as two hypothyroid patients and, due to dictation error, had first time mention of hypothyroidism as a diagnosis and levothyroxine as an active medication. Several follow-up TSH levels were not reviewed, as the paper lab reports were not placed in the chart. On one occasion, a suppressed TSH was noted and levothyroxine dosage was reduced, but the medication list was not updated, leading to the next refill of levothyroxine at the original dosage. Upon discovery, the patient’s levothyroxine was discontinued and follow-up TSH levels are normal.
Discussion: Healthcare systems are well behind recommended goals of transitioning to EHRs. The CDCP’s latest survey reported 43.9% of office-based physicians used an EHR in some way, 20.5% have basic systems, and only 6.3% have fully-functional systems. This case illustrates how an EHR might have prevented several serious errors: patient misidentification, misremembered past medical histories and medications during dictation, failure to integrate laboratory values directly into the patient record, failure to maintain up-to-date medication lists, and failure to follow-up on labs ordered but not resulted. With federal stimulus money directed to physicians for adoption of EHRs, errors such as these should be reduced.
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