Electronic health records (EHRs) are in wide use now, and they have many advantages such as providing easy access to patient records, making medical chart review more accurate and less complex, and increasing patient participation and communication. To enjoy all the benefits and features provided by EHRs, providers must ensure that their EHR entries are all timely and accurate, with the records and test results highlighted if necessary. As a company providing medical record review for medical legal consultants, we understand that the electronic health record can be most helpful to providers in the event of a malpractice suit.
EHR Use in Defense Litigation
EHRs contain extensive documentation and for healthcare providers who systematically complete their medical documentation, their EHR can provide the best defense possible. During a medical record analysis, the medical documentation provides concrete evidence regarding the treatments and care provided to the plaintiff, and comprehensive documentation can be successfully used in litigation. For instance, consider a case wherein the physician informs the patient of his/her condition, the lab and imaging results, and the course of treatment to follow. He/she also schedules follow-up appointments. The patient doesn’t follow the clear instructions given and develops some health condition. When all these details are recorded in the EHR, it is good evidence that the physician had done whatever was required, whereas the patient failed to follow the instructions given. This helps rule out liability or negligence on the part of the physician.
Check out our blog Understanding EHR Entries and Medical Record Analysis
While improving the quality of patient care and reducing malpractice risk for providers, EHRs also make medical record review for defense attorneys easier.
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EHR vs. Paper Records in Litigation Defense
There are certain points to keep in mind when considering EHRs from the perspective of litigation defense. Compared to paper charts, EHRs have advantages as well as disadvantages. It makes processes such as medical peer review easier and more effective. To overcome the disadvantages, healthcare providers have to be cautious when making EHR entries. Only then can the EHR be used effectively in their defense.
Here are some key considerations:
- Patient history and other details can be more clearly documented in the electronic health record. So, if a physician makes a medical error based on patient history, he/she may have a tougher time trying to prove his/her innocence. Also, it is easy to identify that the physician had not made proper reference to the patient history and therefore was negligent.
- Another important thing to keep in mind is that when data is input into the EHR, it is time stamped. In other words, the time stamps in an electronic health record refer to the time when the patient care information was fed into the EHR, not the time when the event took place. For instance, if a provider gives an injection to the patient at 2 PM, and does not close the entry until 2:30 PM, the event could be posted to the record with a time stamp of 2:30 PM.
- EHRs reveal wrongdoings more easily than paper charts. Data loss, data destruction, wrong data entry, alterations to the record, unauthorized access can all be easily identified. So, providers have to be careful to avoid such inappropriate behavior when using the EHR.
- When it comes to printing the electronic health record, it can pose concerns. Most of these records are not designed with printing in mind. They prioritize HIPAA compliance and comfortable screen viewing. So, there are chances that the physician may need to provide plaintiff attorneys and their authorized personnel access to the EHR system, take screen shots of the dialog boxes, and print those.
Making the Best Use of EHRs
If the electronic health record is to be used with litigation defense in mind, when buying an EHR, providers must seriously consider how their EHR’s data entry can be used as evidence in court. Other key things to consider are:
- The differences between the EHR and a paper medical chart, and the various EHR functionalities.
- The EHR templates should facilitate accurate documentation, and in turn improved quality of patient care.
- Ideally, it should be possible for the system to print a complete and intelligible legal medical record.
Providers must use their EHR prudently and carefully to ensure that it will help them with their defense if the need arises.
As far as attorneys are concerned, the EHR is a very useful tool that helps them well-organize, comprehend, and review their client’s healthcare information. This is because the electronic health record provides smooth access to the person’s medical history, diagnosis, treatments and medications, and evidence-based tools that will help support the medical decisions made and the standard of care. The audit trail feature of the electronic health record clearly shows when some information was added, deleted, modified, or viewed – which could be important in medical malpractice litigation. All these are vital to proceed with a medical negligence lawsuit or a health insurance claim.
When used wisely, the data contained in the EHR can be used to establish causation, liability and/or damages. Surely, over time, more efficient electronic health record systems will be developed with vendors, healthcare providers, and attorneys understand the system better.