I represented a child who as a newborn in a neonatal intensive care unit developed a herpes eye infection and later herpes meningitis. A physical examination is recorded each day of the child’s admission. The child’s first physical examination included all normal findings. The same findings, word for word, appear each day to the end of the child’s hospital stay. Nevertheless, at the time of discharge the child exhibited severe brain damage and was blind in one eye.
At 2 weeks of age a lumbar puncture was performed. Progress notes for the next 5 days include a default entry “culture results pending.” In fact, the laboratory reported to the electronic record that cultures were negative and final on day 3. A further lumbar puncture was obtained 9 days after the first lumbar puncture. This time the CSF specimen was submitted for PCR DNA analysis for herpes. The result reported 2 hours later confirmed the presence of herpes. The diagnosis of herpes meningoencephalitis was made and appropriate treatment with acyclovir was finally initiated. Though this disaster was caused by the failure of those involved to have adhered to appropriate standards of practice, the health system’s electronic health record certainly facilitated the unfortunate result.
As was pointed out earlier, making a health record electronic is not useful if the original health record and its use was dysfunctional. An established tradition of non-communication between members of the health care team is in no way improved by making the entries legible. Further, the existence of default entries (prior entry remains in the same field when next entry is to be made and verified or is copied with a key stroke to the same field) encourages physicians to assume the absence of change rather than conducting such examinations and asking such questions as would confirm the absence of change.