Electronic Health Record Documentation In Medical Malpractice Claims

Medical providers who face a claim of medical malpractice depend heavily on their electronic health record (EHR) documentation. Such information serves as an audit trail outlining the care provided. Often this critical data is insufficient, such as when it contains incomplete exam or visit notes, shows untimeliness or lapses in care, or notes that were not properly signed.

Health care practitioners participating in the Medicare Quality Payment Program must maintain an EHR system that is compliant with Certified Electronic Record Technology requirements. This compliance is critical not only for having documentation for defending against liability, but also is necessary for obtaining reimbursement for care provided to patients on Medicare.

Audit Trails

EHR systems generally are able to produce a report or a summary of all activity related to a particular patient’s care. This audit trail should show time-stamped entries of all activity including creating, editing and viewing a record. There should be a chronological history of all activity such as examination notes, conditions diagnosed, prescriptions written, etc.

Three Keys to Improving an Audit Trail

To maintain proper records the report or summary should show:

• That notes are signed promptly by the proper individual(s) responsible for the care
• Incoming messages and patient information are properly entered into the system, reviewed and responded to
• Open or pending items or actions are being addressed in a timely manner

Care Management Solutions

Provider reimbursement, such as for care provided to Medicare patients, is increasingly “value-based” today. This has made it necessary to adopt the concept of care management. Care management was traditionally used in caring for “high risk” patients, such as those with multiple chronic health conditions. This involves a systematic process that assesses patients, creates a specific plan of care, and ensures proper communication between providers and their patients. There is software now used specifically for care management. This critical data is also likely to be scrutinized in the actions of medical malpractice.

Risks & Challenges

Medical practices are now challenged with potentially maintaining documentation in their EHR system and a care management system. These two systems may be incompatible and cause a greater administrative burden. When a compilation of reports from both systems pertaining to a particular patient is reviewed, often the care provided will appear as being fragmented. As a patient is seen by other medical providers, these individuals may not have access to critical patient records and data contained in other software systems. Plaintiff attorneys could clearly use this information to show how a patient’s care lacked continuity.

Current Care Management System Options

There are three primary options in the current market for care management systems. These include EHR vendors, health plans, and new care management startup companies that sell “standalone” products. Many of the EHR vendors have simply added their care management solution as an add-on module to their existing record systems. Health plans that have developed solutions often refer to them as “case management” solutions and may be considered as value-added offerings. Some of the most common conditions that are tracked in care management systems include respiratory problems, heart conditions, cancer, and arthritis.