The electronic medical record was introduced with a view to effectively address medical charting and documentation issues and facilitate processes such as record retrieval, medical record organization and review. Though the electronic health record has improved the medical billing process and enhanced documentation, it has also brought with it a number of concerns. One of its main advantages is that the records are legible and so medical errors can be minimized. However, now certain inherent problems are surfacing that are a real concern for attorneys who need to work with their clients’ medical records.
- Risks associated with the electronic health record: The technology itself may have intrinsic errors. Consider the case of health systems where more than one EHR system may be implemented. It is vital that clinicians understand how the various programs interact and communicate with one another. Also, both hardware and software may need technical support, and have to be updated. The downtime that results from these can lead to errors in EHR entries. If a system update is occurring when a physician makes a documentation, or if an update is unable to upload because a clinician is using the system to review a file, problems can arise. When there are multiple systems in a hospital and one of these systems updates, it could cause an interruption in the communication between systems.
- Human errors: These comprise documentation errors made by physicians, nurses, and other care providers. Various fields in the electronic health record are filled by humans, and there is the issue of copy-pasting previously entered data. If the clinical staff or physician fails to enter a new diagnosis or medication change, and indulges in copy-paste, there could be serious issues. Mistakes could occur when checking boxes, deleting or saving EHR entries, entering dates and numbers, and so on. Other human errors include duplication of data and inconsistency in record-keeping.
- Difficulty locating data that may be buried deep in the chart: Attorneys who are untrained in EHR systems will find it difficult to wade through the voluminous records. The problem is clinical notes, such as nursing notes, may be entered in more than one part of the medical record. Typically, nurses may enter their notes into a flow chart, progress note or the MAR (Medication Administration Record).
- Duplicate entries: Physicians and other clinical staff may make duplicate entries, which could lead to challenges in identifying whether entries are absent, identifying missing documents and so on.
- Difficulty in organizing the records: This results from the medical records being printed in a haphazard order. It becomes difficult to organize the records in chronological format and ensure whether the chart is complete. There could be a lack of consistency as well that adds to the challenge.
- Complexities posed by templates and checklists: These features of the electronic health record make it quite difficult for the attorney to determine whether a particular part of the body was actually examined, or whether the data was automatically entered due to the template.
- Confusion regarding the programs that healthcare organizations use: Attorneys need to understand which programs are being used by a particular institution. EHR vendors offer distinctive programs that function differently. The same provider may be using different programs. EPIC, for example, has created programs for different areas of medicine such as cardiology, obstetrics, ortho, endoscopy, oncology and radiology. When placing a request, the attorney has to consider the specificity of the request as well, or records particular to a specific program.
- Understanding audit data: Audit data is relevant during the discovery process. Most electronic medical record programs allow downloading the audit data in Excel format. Attorneys should also request a copy of the data dictionary for the particular EHR system. This document contains the names of various events, modules, types, and descriptions which mostly appear only as acronyms or codes within the audit data. Sometimes, you may need the assistance of an IT expert to understand the data.
Attorneys involved in medical litigation and companies providing medical chart reviews for them understand that the evidence or data obtained from electronic medical records has limitations. Sometimes audit trail information may not be clear, as for example, regarding who reviewed a particular test result, and when. This is caused by multiple staff members logging into the system and leaving it open for other team members to use as required. This is typically done to lessen the need for each member to log on and off in a busy medical setting. Thus the electronic medical record can make the attorney’s job more intricate. While entrusting the medical record retrieval, organization, and review to a medical review company is a feasible option, it is best that attorneys take an effort to have a grip on the distinctive issues that EHRs create and understand how these can be effectively handled.