Medical records are highly sensitive documents that need to be kept confidential at all times. Now, with the advent of electronic records, safety of protected healthcare information is becoming a major concern. Electronic records have many advantages over paper records, lightening the documentation burden of physicians and providing easy access whenever needed. However, EHR systems are proving to be vulnerable to deliberate tampering. A reliable EHR system would be one that does not compromise patient confidentiality. Safeguards must be implemented to ensure that inappropriate persons do not view the medical information.
Consider the recent case at an Australian hospital, when a radiologist found that his patient’s records that had critical notes regarding hospital management were missing. It is suspected that the concerned records were deliberately removed though it is not clear what spurred this action. Missing records and compromised healthcare data can pose real challenges in the context of medical claims review and medical record review required for legal purposes. The fact that serious breaches can occur in the EHR system is rather alarming and is likely to have serious implications for legal cases. In fact, it throws suspicion on the integrity of the entire medical record system. The fear is that the entire patient administration system could become worthless by the act of a single person. Sources say that the decision to erase the record in the above case was made by a senior clinician and management. The hospital staff however, claims that they cannot access the electronic system to delete medical records and that somebody with access above doctors’ privileges may be responsible for deleting the information.
Incidents such as these draw attention to the significance of patient healthcare documents, underlining the need to ensure their security and confidentiality. It also highlights the importance of identifying missing records during the review process because their absence may portend something much more serious. Moreover, it is important to understand that only the expert, experienced eye of a medical professional such as a physician or registered nurse can detect such discrepancies in the patient chart. Attorneys and lawyers involved in medical litigation should in the best interests of the cases they handle, ensure that they utilize medical review services wherein the team includes experienced medical personnel. In this way, missing records can be identified at an early stage itself and steps taken to retrieve them if available. If they have gone completely missing, it may throw light on another dimension of the case.