Defective Medical Records – a Real Concern

by | Published on Aug 23, 2013 | Medical Record Review

A major concern at present is whether the electronic medical record systems available now can provide accurate healthcare data. There are class action suits involving EHR manufacturers, which is indeed a matter of grave concern.

With the drive for EHR implementation, physicians are under tremendous pressure having to enter patient details into the medical records in a timely manner. Work pressure forces many physicians to utilize the copy-paste feature available in the EHR system, which can result in copying outdated or inaccurate information. This can compromise patient safety and lead to undesirable outcomes. The main concerns physicians have regarding EHR are software and design flaws, and the lack on interoperability among various electronic health record systems. When there is no co-ordination among the EHR systems, potential threats include missing/incomplete information. This poses the danger of erratic diagnosis and treatment.

Erratic medical records are a major issue when it comes to medical litigation that relies entirely on the facts that can be extracted from patient medical records. Such records can seriously hamper justice.

Taking into consideration the possibility of erratic EHR systems, the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology has facilitated confidential reporting of IT-related adverse events. This is with a view to improve patient safety. As a certifying body for electronic health records technology, the ONC will strive to ensure that EHRs make it easy to report patient safety events and hazards via common reporting formats developed by the Agency for Healthcare Research and Quality. This kind of confidential reporting is expected to help understand common problems associated with EHRs, their frequency of occurrence and how they can be set right. We can only hope that the “bugs” and “glitches” associated with electronic health records are effectively eliminated and patient safety safeguarded.

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