Electronic Health Record (EHR) systems, also referred to as electronic medical record systems, are now widely adopted among the U.S. medical community. Roughly 87% of physicians who are based in an office setting use an EHR and over 75% employ a “certified” EHR which meets enhanced standards. Since 2008, the number of physicians using an EHR doubled from the 42% rate at that time. As with any newer technology, the improvements tend to occur quickly and many users encounter flaws in design and difficulties with complexity and often will adopt careless practices.
Dr. Jeffery Kagan of Newington, Connecticut, has been working to analyze claims of medical malpractice. He reminds users to remember that an EHR can be source of potential liability for medical providers. He explains that many claims of malpractice has been the result of template-based medical records, which are designed to increase efficiency through more simplistic lists and fields that use drop-down boxes. Sometimes the templates have a problem where they retain unnecessary or outdated information. The issue may be resolved with minor editing; however, some providers are either unaware or unwilling to do so.
Often physicians will develop lazy methods of creating their medical documentation through template usage that fails to accurately document the patient status. It is recommended that doctors pre-evaluate and modify templates prior to using them. Other problems may involve a doctor failing to pay attention to the patient during the visit or reduced interaction with the patient as that try to complete the template at the same time. Many templates also have an “autopopulate” feature that references words used in prior entries that can lead to the entry of the wrong information which creates costly errors. In addition, many of the templates are designed to better streamline the billing process, but actually are inaccurate for the purposes of creating a proper medical record.
Some of the template structures that are created have problems interfacing and the information can be recorded in a manner that does not truly reflect the intended purpose. Many malpractice claims have centered on poor record keeping, which an EHR is supposed to improve. Some automatically generated reports become “garbled” and do not position the data in a proper order that can be interpreted. Another major concern relating to interfacing is how one provider’s EHR system may not have the ability to communicate with other systems, essentially creating a fragmented medical history across the continuum of a patient’s care.
The government has been adding specific requirements that are necessary to avoid losing reimbursements. Management and administration often tends to shift the main focus of the EHR to maintaining this compliance, but may fail to address the critical documentation that is very important in the event of a malpractice claim. An example would be customizing a template to conform with the Medicare requirements, that does not include critical data that a subsequent provider must have as a reference for a particular patient.