Reviewing Electronic Medical Records – New Challenges for Legal Entities

by | Published on May 11, 2015 | EHR/EMR

The transition to electronic medical records has considerable impact on both healthcare and legal entities. While EHRs do have their merits, there are certain challenges that are difficult to deal with. One major problem is when the record system is a “hybrid” one involving paper as well as electronic records, both of which have to be reviewed. Another issue arises when EHRs are not regularly updated or when systems crash – in both scenarios the healthcare information available may be inaccurate and have a negative impact on the efficient and effective discovery of healthcare records.

Drop-down menus in electronic medical record systems pose a serious problem. These allow healthcare providers to choose from a number of options. When a paper printout of the electronic record is used for legal purposes, the lawyer must carefully review each page because often the printout may differ from the content that appears on the healthcare provider’s interactive computer screen. Thus there may arise a discrepancy between what the provider viewed on the screen at the time of the particular entry and the content in the printout. Deposition of a healthcare practitioner becomes challenging in such instances, and can be solved only through proper preparation, specifically studying the differences between the paper printouts and the initial interactive computer interface that the provider used.

Yet another problem with a digital health record system is delayed entry of data. The system may show only the actual time the information was entered and not the time when the specific treatment occurred/was completed. This creates confusion when a medical chronology is prepared because the time stamped on the record and the time of completion of a particular procedure will not tally. The witness’s testimony may lack credibility in such an instance and may even create the impression that the healthcare provider tampered with the documentation. EHRs also allow one provider to enter data on behalf on another. This is a legal hurdle because the practitioner who provided the treatment or service may not be the one documenting it. Lawyers have to be extra careful in this regard and ensure that they are questioning the actual provider of service and not the one who entered the data. In all such instances, clear-cut communication and detailed review of the records must be made by the attorney beforehand.

There are other issues as well with digital record systems such as copy-paste problems and error-correction. To identify all such problems and ensure that they are working with accurate medical data, attorneys can seek expert medical review services. An experienced medical review company will take care of all requirements right from records retrieval, through organization, chronology preparation, analysis and summarization. Legal entities can then work with unambiguous healthcare information, develop their argument well and go on to win the case.

Discover our medical record review solutions and partner with us for your next case.

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