An electronic health record (EHR) is more than just an electronic representation of a paper chart. It is a legal representation of a patient's medical condition and treatment at a given point in time, one that could be admissible in court. And that could present a whole new set of challenges for healthcare organizations.
"There is no guide out there to walk people through all that changes with an EHR," Adam Greene, a Washington, D.C.-based partner in the law firm of Davis Wright Tremaine, said this week at the American Health Information Management Association (AHIMA) Legal EHR Summit in Chicago.
EHRs make patient information more readily accessible to far more people than any paper chart stashed away in a filing room. They also change how and to what extent medical professionals document patient encounters and add in safety-related features such as clinical decision support.
"There are all sorts of liability fears with all these improvements," Greene told InformationWeek Healthcare. The Health Insurance Portability and Accountability Act privacy and security rules require anyone that handles electronic healthcare data to keep an audit log of access to any personally identifiable information, and records have helped organizations catch employees taking unauthorized looks at patient records--sometimes also landing the organizations themselves in hot water.
Indeed, some worry that audit logs can reveal too much. "There are concerns by providers that access reports could be used in malpractice suits," Greene said.
In fact, such reports already are, according to Stacey Cischke, an attorney with Chicago firm Cassiday Schade who teaches a course in legal issues in e-health at Loyola University Chicago. "The scope of traditional discovery is expanded," Cischke said. "More and more courts are finding that metadata and access to the inner workings of the EHR system is relevant and discoverable."
The general public and even plaintiffs' attorneys do not always comprehend how EHRs work, Cischke added. Because there is so much to chart, physicians and nurses are rushed and things get missed. From the patient's perspective, all the doctor should have to do is click and check off boxes in a list, but, according to Cischke, physicians often are "overwhelmed" by time and economic pressures, and skip steps or simply forget to check some boxes. "The metadata will show this," Cischke said.
Cischke said she prepares clinicians for trial by making sure they understand what each piece of metadata means. Knowing when something happened then opens up questions of why the doctor took a certain action.
On the other hand, with an EHR, users can't "fudge" charts as they could with paper, since EHR systems generally won't allow any modifications after a physician signs off on the record of a patient encounter. But plaintiff's attorneys do not always consider this. "It's logistically challenging," Cischke said. It is hard for the layperson to understand individual records, flow sheets, and audit trails.
Thus, Cischke recommended that providers adopt a multidisciplinary approach to identifying potential lawsuits, and promote consistency in how they produce reports and respond to threatened legal action. Both in-house and outside counsel and staff need to learn how the EHR works and how to navigate through electronic records before they find out the hard way, after being sued.
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