Transitioning To Electronic Health Records
The introduction of Electronic Health Records (EHR) was intended to make the overall process of keeping patient records more streamlined and effective. It also had the added benefit of lowering health care costs, and the system is slowly being used at more health care facilities. However, there are some drawbacks that are only now being discovered, despite the system’s obvious benefits.
One scenario that can be potentially damaging is that the medical condition and details of a patient may not ever be recorded on a paper chart, although they are recorded in the EHR of a particular hospital. The AAOS (American Association of Orthopaedic Surgeons) points out that this is a potentially simple error, yet could have harmful ramifications if the medication was prescribed or adjusted based on the electronic or paper record alone. It can take more time and effort to verify a patient’s information by checking all forms of records, although this would have to be done during any transition period from paper to electronic, to avoid potentially fatal errors.
EHRs can help to avoid these mistakes and potentially reduce physician liability; they are easier to read and decipher than handwritten notes, and avoid any mistakes caused by unforeseen allergies or reactions to medication. However, it is important to coordinate fully between the two forms of record keeping while the transition is being made from one to the other.
Source Of Record
The authoritative point of information that exits in one place in multiple locations is described as the system, or source of record. A health care institution may well rely on the patient’s paper chart, even though the information is also being entered and stored electronically; in that case, the source of record is the paper chart. In most cases, it is up to the individual physician to make this decision, and as of now there are few overall standards.
In Oklahoma, a patient was misdiagnosed and later died, because a physician did not check the electronic records, instead relying only on the paper chart. The court ruled that it was the responsibility of the doctor in question to check both forms of patient records before making an important decision and diagnosing the patient. Of course, in order for this to be effective, good coordination between the two systems of storing data is essential, and many point out that it simply adds to a doctor’s many existing duties if they have to check two different sources in order to avoid cases of medical malpractice in Oklahoma.
When patient information is shared, a secure network must be used, according to the HIPAA (Health Information Portability and Affordability Act) which means that Gmail and other email programs widely used by the public can not be used. A smart phone, tablet or other handheld electronic device could potentially be used to access Electronic Health records, although it would have to be restricted to a secure network, and all the staff would need to have access.
A possible problem with this system is that a member of the public could potentially access an unattended terminal, but one that was logged on to the system, making it imperative that users log off after use.
Physicians are also more likely to order expensive and sometimes unnecessary diagnostic tests, if they are working with Electronic Health records, according to a recent blog by Harvard Law health care. Care would have to be taken not to increase costs for no good reason, as the point of the system is to save both money and time; at the same time, great care must be taken not to make errors.
Inevitably there will be a transition period between the use of paper records and the use of electronic ones, and during that time, physicians should be extremely careful to protect themselves and learn about their potential liability, despite the fact that all that takes time. Understanding what the patient access policies are and which information sources are secure and reliable are essential to help reduce physician liability.
Matt Scyoc blogs and consults for Lawter Law based in Oklahoma. Matt blogs regularly about legal news as well as updates within the legal community. For more info about Matt, you can connect with him on Google+ and on Twitter @LinkSource.