Across the country, more and more medical practices are turning to electronic medical records (EMR) software to help them better manage the sheer volume of patient data they generate and accumulate, as well as to comply with some federal mandates. As a defense attorney, who is pleased that I can finally read my clients’ medical charts, I must say, the new technology is both a blessing and a curse for my clients.
There are a number of benefits to using electronic health records. Chief among them are how quickly and conveniently the medical providers (themselves or through a scribe) can enter and access patient data. The promise of consolidated records is another major benefit of EMR software. The patient’s history, diagnostic test results, as well as medical imaging can be integrated or consolidated into a single set of records, easily accessible via any computer. The software also enables efficient processing of patient information. This aspect of it, not only ensures efficient treatment and management of the patients, but from a financial aspect, it helps ensure prompt payment from entities such as Medicare and Medicaid.
Further, the software is a useful guide to ensuring a thorough and extensive examination of each patient. EMR software typically comes with optional expansion modules, such as templates for specialties. The software presents various data fields that must be filled out, and won’t allow the examiner (or scribe) to progress to the next page until the required information is entered. In addition, every entry and modification is generally time stamped, which makes it nearly impossible for a modification to a chart to be made after a lawsuit is commenced to go unnoticed (Yes, unfortunately we see this sometimes).
Despite the benefits of EMR, this modern way of record keeping carries with it some major concerns and downsides. First, patients’ privacy is a major concern. The use of EMR software can potentially expose practitioners to federal violations if they do not follow privacy protocols to an exacting degree. Additionally the convenience and immediacy of EMR make it easier to violate privacy at an unprecedented level. This can also lead to identity theft when unauthorized people gain access to confidential and sensitive records. However, EMR software alone is not to blame for such an unpleasant scenario since it is possible to commit identity theft simply by accessing paper records of patients.
In addition, data loss is a major issue when it comes to EMR. An event resulting in a loss of years of information could jeopardize the medical providers’ ability to ensure continuity of care for all the patients. Therefore, those who have implemented the use of EMR software must be cognizant of the importance of an extensive backup system or cloud.
Another, unfortunate result of EMR is that plaintiffs in medical malpractice actions making more claims related to negligent record keeping. This seems counterintuitive considering the electronic records are more extensive and legible than the old school paper charts. However, plaintiffs are using the system, which comes with various defaulting templates, to argue that the medical providers are not really conducting the thorough examinations of their patients as indicated in the charts, they argue that the findings are merely default findings from a previous page or a click of a computer key. The sad truth is that there are glitches in the systems that support some of their arguments, which means that the medical providers need to be very careful when clicking away at the computer. My favorite example of this: when a patient was noted to be pregnant. That patient was 2 years old! Same thing happened for a patient who was undergoing a tummy tuck. While a first time pregnant woman might be very self-conscious about the changes in her body, I’m fairly certain that a tummy tuck is not the answer! You see my point.
Unfortunately, we are seeing a rise in claims regarding record keeping since the implementation of electronic medical records. I recently spoke with a doctor friend who conveyed his frustrations as such:
“The quality of my work was no different with or without my expensive electronic medical record system, or my scribe for that matter. The outcomes of my surgery and my visits with my patients should be the focus of my practice, not the checking of a box so some overly aggressive attorney cannot accuse me of a false record keeping and/or inadequate exams.”
Sadly, I have found that while EMR is beneficial to the physician and patients, the modern way of record keeping has just added fuel to the fire of an already litigious society.
Hillary Agins began her career as a public defender for the Nassau County Legal Aid Society before moving to private practice in 2002. A former ski instructor, Hillary has a secondary interest defending medical negligence and premises liability claims against ski areas and resorts.
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