Caution: Electronic Medical Recording has accuracy and reliability pitfalls physicians should avoid

Judges reviewing EMRs in medical malpractice cases have expressed concerns over the manner in which records are kept using EMR software and pre-populated forms and checkboxes.

Judges reviewing EMRs in medical malpractice cases have expressed concerns over the manner in which records are kept using EMR software and pre-populated forms and checkboxes.

Electronic medical records (“EMR”) might make it easier to see more patients and spend more time caring for patients, but there are inherent risks in technology and human error that can hurt physicians in lawsuits.

Judges reviewing EMRs in medical malpractice cases have expressed concerns over the manner in which records are kept using EMR software and pre-populated forms and checkboxes. When a patient’s medical record is an adjusted template report it is too easy to inadvertently replicate data in a cut and paste process, leaving a trier of fact reviewing the records to question the accuracy of the reported information. The traditional manner of making individual patient records contemporaneously with care is a tested and accepted practice. It might take more time but more authentic records might stand up better under scrutiny.

Documentation of critical findings using EMRs can increase malpractice risks.

  1. Timing of patient diagnosis and care might not be accurately represented in EMRs. If a doctor sees several patients and takes some notes during the short time between patients then makes the EMR entries later that day, the timing can appear incorrect. In one instance, a judge questioned why a diagnosis was reported to have been made at one time and treatment took place six hours later. The physician actually treated the patient within a few minutes of the diagnosis, shortly before noon, but the notes were not added into the EMR until the early evening. Ideally, data would be entered contemporaneous to live events to establish an accurate record of time.
  2. Content and data copy and paste issues are known to lead to confusion and concern. A judge in one case commented on copy and paste errors: “I cannot trust any of the physician notes in which this occurred, and the only conclusion I can reach is that there was no examination of the patient … it means to me that no true thought was given to the content that was going into ‘the note.’[i]” If a mistake was made and a cut and paste error occurred at a prior time in the patient’s history, that incorrect information could be duplicated again. Without better information, it is difficult to rely on data kept in this manner.
  3. Pre-populating forms are also problematic because it is hard to know whether template language was inadvertently selected to be stated in the medical report. The traditional reporting methods using individual data manually recorded is less likely to lead to a medical mistake if a healthcare provider innocently relies on incorrect EMR data and causes harm.
  4. Checkboxes to respond to yes or no questions, and or to trigger pre-populating data are also easy enough to miss or check in the wrong spot in EMR software. An inadvertent mistake causes the same concern for data accuracy.

Despite the concerns about accuracy of information on EMRs, there are several methods a physician can use to best insure the accuracy and reliability of the information. Using specific information and custom reports might take more time but could save the day if the records are ever scrutinized down the line.

Michael V. Favia & Associates are available to assist physicians with professional licensing matters and lawsuits for medical negligence and patient death. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. For more about Michael V. Favia & Associates’ professional licensing work, please visit www.IL-Licensing.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter.

[i] KevinMD.com blog, EMRs can hurt physicians during lawsuits. Here’s how. By Keith L. Klein, MD, Jan 10, 2015.

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