Increasingly hospitals and physician offices are converting to electronic records. There are risks and benefits to this method of documenting medical information.
1. Most EHR (Electronic Health Records) software systems have the ability to ‘auto-populate’ data fields. A key data element, such as an allergy to penicillin, need only be entered into the record once and it will be automatically entered into every other area of the record which requires allergy information. When the wrong information is entered into one of these key fields, that error will be auto-populated throughout the record and may cause medical error. The reviewing attorney should be aware of this weakness in electronic records and its connection with adverse events.
2. All facilities which have converted to EHR need to have tested protocols which allow all practitioners to continue documenting smoothly during those times when the EHR system is ‘down’. When reviewing a copy of an electronic record, the attorney should note any unusual gaps in the record since those gaps may indicate a systems issue and the existence of (or lack of) manual records produced during those gaps.
3. One of the most obvious benefits of computerized medical records is the creation of legible records. Printed records are completely legible, therefore eliminating the confusion caused by guessing at the meaning of handwritten words.
4. The identities of the healthcare providers are easy to determine, as each entry is followed by either initials or a full name and status MD, RN, LPN and so on). If the entry is followed by initials, somewhere else in the document the person’s full name will appear.
5. A New Jersey hospital employee, Enzima Obie, undergoing testing in anticipation of surgery received a false positive HIV test result. A second test returned a negative result, leading her physicians to conclude that the false positive was related to her recent case of malaria. A suit ensued after a lab employee reported the first test result to the employee’s supervisor. HIV test results were kept in a binder that could be viewed by any hospital employee. When Obie applied to return to work after surgery, her supervisor advised her that she would be placed on a preferred hiring list, but she was never rehired even though there were several vacancies she was qualified to fill. After a 10-day trial, the jury found the hospital violated the Aids Assistance Act and awarded $200,000 in compensatory damages.
6. Computerized medical records pose new challenges to the healthcare provider’s ethical and legal obligation to safeguard confidential information and comply with the provisions of the HIPAA. In 2011, Massachusetts General Hospital was fined a million dollars after one of its medical residents accidentally left a laptop computer on a subway train. The computer contained patient data.
7. Dedicated hackers may breach the security of electronic health records, gaining access to potentially embarrassing details about an individual.
8. Physician and nursing resistance to the use of computers is a factor that complicates the introduction of computers to a healthcare setting. Partial use of the computer and partial use of handwritten entries can create a confusing record.
9. Computer systems may become unavailable due to unexpected crashes or routine downtime. Medical information becomes inaccessible during these times, creating potential for medical errors.
10. The adage “garbage in, garbage out” applies to the computer medical record just as it does to other aspects of computer programming. Attorneys and healthcare personnel must guard against the temptation to deify the computer. Meaningless documentation can also be generated when templates are used without modification or individualization.
11. There are dangers in using templates, or copying and pasting information into an EHR system. There are dangers in providers sharing logins. There are dangers in providers modifying or deleting electronic entries after the fact of treatment. There are dangers in a hospital having several EHR systems that do not communicate with each other. Data can be corrupted or lost.
Pat Iyer and Lee Houston, two legal nurse consultants, created a practical program on how to analyze computerized medical records. . Computerized Medical Records: Medical Legal Analysis is an all new one hour multimedia program geared to attorneys and legal nurse consultants. You’ll come away with concrete suggestions for making it easier to review records on the computer monitor. Buy the CD, MP3 audiofile, replay or transcript. Get details about a computerized medical records webinar here.