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​Health information technology (IT) has long been lauded as a necessary ingredient for achieving the Institute of Medicine's (IOM) so-called triple aim of healthcare quality improvement (better individual care, better overall population health, and reduced per capita healthcare costs). But without also addressing the current medical liability system and the impact that health IT will have on it —adding a fourth item to IOM's quality improvement list—"even the idealized discussion of achieving the triple aim will be a hollow victory," says James B. Couch, MD, JD, FACPE, senior physician executive, the JHD Group, Inc., and author of the new book Achieving the Quadruple Aim in a Technology-Driven Transformed Health System: Better Care, Improved Health, Lower Costs and Decreased Medical Liability.

"Healthcare reform will not be successful without dramatically increasing the role of health IT in the delivery and financing of care," Dr. Couch tells ECRI Institute. He points to "the dramatic need for real-time decision support, which requires actionable, reasonable, useful, and user-friendly information for both patients and practitioners."

In his book, Dr. Couch, who describes himself as a "radical independent pragmatic centrist," describes the face of medical liability in the world of healthcare reform, in particular how health IT like electronic health records (EHRs) can influence care in ways that can drive healthcare costs and quality either up or down.

"We've got to start looking at this pragmatically from the perspective of the payer—and the patient, who is increasingly the payer—how defensive medicine is causing the cost of medicine to go up, causing premiums to go up, causing employers to drop insurance, if still legally permitted to do so. We've got to get away from politicized complaints. The healthcare system has been broken for decades, and we've got to come up with pragmatic nonpartisan solutions to reduce liability."

The current state of EHRs, Dr. Couch says, may increase the likelihood of liability on at least two fronts: how clinical decision support is used (or not used) and the comparative "user-hostile" nature of many EHRs that can make physicians less likely to use them at all.

"Used appropriately—not ignored, abused, misused, overused—clinical decision support will improve quality, safety, and efficiency of care," Dr. Couch says. "But the way it's been designed, often without the input of caregivers and necessary interoperability to permit communications among practitioners and other providers using different proprietary systems . . . We've got a long ways to go for real-time clinical decision support."

Risk managers should be on the lookout for ways physicians and other providers work around existing clinical decision support, and how it can affect care, Dr. Couch advises. "Physicians—employed or otherwise—they get so frustrated by alerts that they don't install them, turn them off, override them, or set thresholds so high that they don't fire in the absence of life-threatening situations. The very functionalities that are intended to improve quality and reduce liability won't help if they're not installed, or otherwise misused. But physicians have discussed how they've been slowed up by them; so many are ignoring the alerts."

Having clinical decision support, no matter how poorly designed, available but not using it will create a high hurdle in defending any liability case. "If there is an adverse reaction or a bad outcome, e-discovery will call it out," Dr. Couch says.

Pressed for answers at deposition or at trial, "will a physician be forced to say about an alert, 'I just ignored it'?" Dr. Couch asks. As for what risk managers can do, Dr. Couch encourages them to look at "how and to what extent these triggers are being used, or not used, or abused, or not even installed."

 "If I were a risk manager—in a hospital, emergency room, intensive care unit—I'd try to understand the alerts and what's happening with them," he continues. "I'd survey providers in as anonymous a way as possible. What are they [the alerts]? What do you do, or not do, about them?"

In some ways, Dr. Couch states, EHRs have come to be seen by physicians as an enemy of good care. "A strong majority of doctors say the EHR is adding time and hassle to their days. Now physicians who can't afford scribes need to stay an extra hour or two later to get the EHR to do what they wanted it to do when patients were there but they didn't want to sit there with their back to the patient" during an exam, he says. However, waiting until the end of the day to enter information into the EHR certainly carries with it its own risks accompanying faulty memories and inaccurate data entry.

If he could wave a wand and implement one change to overcome the problem, Dr. Couch's wish would be better voice recognition software. "Most physicians, especially of a certain age, are not great typists. Dictation is well within their comfort zone, especially for surgeons and others who do a lot of procedures. Voice recognition will be critically important."

"If I'm talking to a patient, examining a patient, coming out of surgery, I need to be able to begin to dictate like I would do with a Dictaphone, in olden days. It would be a huge improvement, assuming that it's accurate, good, and reliable and doesn't involve sitting at a keyboard," he says. "The easier it is, the more it will reduce the risk of liability."

In the end, Dr. Couch strikes an optimistic note—albeit one with caveats. "As we move, finally, from volume-based to value-based care delivery, we need to reform the liability system just as thoroughly. First and foremost, we need to banish the myth that 'more care is better care.' For decades, that mantra has sustained financially both the healthcare and medical liability systems in the guise of improving the quality and value of care. That myth must be debunked for the last time now."

"I just can't possibly imagine that this is not going to happen this time, after having advocated for this, myself, for the past 40 years," he says. "It is happening, and at a more accelerated rate than I've ever seen."

For more information on Achieving the Quadruple Aim in a Technology-Driven Transformed Health System: Better Care, Improved Health, Lower Costs and Decreased Medical Liability, contact Dr. Couch at or see Nova Science Publisher's website at

Topics and Metadata


Health Information Technology; Electronic Medical Records; Alarm Management


Hospital Inpatient; Physician Practice; Emergency Department; Hospital Outpatient; Ambulatory Care Center

Clinical Specialty



Risk Manager; Regulator/Policy Maker; Patient Safety Officer; Clinical Practitioner; Quality Assurance Manager; Industry; Legal Affairs

Information Type


Phase of Diffusion


Technology Class


Clinical Category



SourceBase Supplier

Product Catalog


ICD 9/ICD 10






Publication History

​Published February 1, 2015

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