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Electronic Medical Records

The Electronic Medical Record

Upon entry into any medical facility, the first thing you do is fill out a form with your name, address, insurance coverage, etc. This starts your electronic medical record (EMR) for that visit.

An EMR is a digital record of everything that occurs during a patient’s care and treatment. EMRs are used in clinician offices, clinics, and hospitals. An EMR is a collection of medical information about a person that is stored on a computer.

An Electronic Health Record, or EHR, goes beyond standard clinical data collected in the doctor’s office. An EHR is a systematized collection of patient and population electronically-stored health information in a digital format. These records can be shared across different health care settings. Essentially, it is a group of EMRs. An EHR contains information from all the clinicians involved in a patient’s care. Laboratory and specialist information is also included.

Anyone who has sought care in a medical facility has a digital record of what happened to them at a given facility. These records are used for many purposes, including communicating between medical personnel, billing, generating discharge instructions, and -- should it become necessary -- telling the story of how you were injured by medical negligence.

A Brief History of the Electronic Medical Record

Electronic Medical Records (EMRs) have been around for years. In 2009, a federal law known as the “HITECH Act” extended privacy and security requirements to electronic data as an extension of the federal HIPAA law. (HIPAA protects private patient information.) As a result of the HITECH Act and other new federal laws, physicians and hospitals were given financial incentives to begin using Electronic Medical Records. In order to receive money from the government, physicians and hospitals were required to use “Certified” EMR technology. The laws dictated what functions the EMRs had to have in order to be considered “Certified.” Among other things, EMR data must be preserved for at least six years, or even longer if the laws in your particular state are more demanding than the federal law.

Why use Electronic Medical Records

The hope for the implementation of electronic medical records was for providers to have easy access to a patient’s health information no matter where the patient was. If a patient who resided in Texas was on vacation in California and in a motor vehicle crash and unable to communicate, the doctors in the California trauma unit could access the patient’s prior medical records. This would allow the doctors to view data such as the patient’s medications and past surgical and medical history, critical pieces of information when treating a trauma patient. Unfortunately, this has not really come to pass. It still remains difficult and time-consuming for one hospital to obtain a patient’s records from another hospital.

The reason a universal database for a patient’s medical records has not materialized is due in large part to unanticipated difficulties with interoperability (“talking between systems”) of different EMR systems. There are well over 1,000 different EMR systems available. These companies did not create their systems to “talk to” other systems. Even if different hospital systems use the same EMR vendor or program, they do not necessarily have the ability to access each other’s records. For example, the Cleveland Clinic utilizes a program called EPIC. Kaiser Permanente also uses EPIC. But, a Cleveland Clinic doctor cannot simply use EPIC to access Kaiser records for a patient, even with the patient’s consent.

To add to the difficulty, hospitals may often use more than one EMR. For example, a hospital may use Meditech for their Emergency Room documentation, McKesson for their inpatient documentation, and Cerner for their lab systems. Although there is some interoperability between these systems in the hospital, it is entirely possible that nurses caring for patients on the floor may not have access to the Emergency Room records. Making the communication more difficult is the fact that some documents, such as anesthesia records and ICU flowsheets, are still handwritten. These are called Hybrid records (both electronic and handwritten documents). The handwritten documents are then scanned into the EMR and the original handwritten document is shredded leaving only a copy of the original. Often the quality of these scanned items lack the clarity and quality of the original document. They also prevent handwriting experts from evaluating the authenticity of the original document.

The good news is that with the advent of large hospital systems (hospitals, doctors’ offices, outpatient clinics, etc.) being owned by the same entity, the trend has been for all care settings owned by the hospital system to use the same EMR or ones that “talk to” each other. For example, if you go to the Emergency Room one day and then follow up with your doctor the following week, your doctor can access your Emergency Room records. This system-wide interoperability also allows your physician to access test results as soon as they are available instead of waiting for them to be faxed or sent via “snail mail.” This only works if your physician is a member (employed by or on the staff of) the large hospital system.

Patients also can access their data via patient portals. After being viewed by the physician, lab work and test results can be added to the portal. Patients can communicate with providers via a portal and even request appointments. It is important, however, for patients to understand that what is uploaded by their doctors to the patient portal is a very small subset of the patients’ actual electronic medical records.

Electronic Medical Records also have other advantages:

Inputting data into and using an Electronic Medical Record

In general, EMRs allow for faster documentation by using drop down menus, shortcut buttons, and/or templates. These allow providers to simply “point and click” on items instead of typing everything out. Of course, every EMR has the option for the provider to type a “freehand” or narrative note that could include information the “point and click” options don’t offer. EMRs utilize icons to alert nurses that a new order has been placed or alert a provider that a test result is back. EMRs also have a general information screen which -- at a glance -- shows important data such as allergies and medications. EMRs also have several layers. For example, a physician can click on an order for a chest x-ray and review the order. A second click can allow immediate access to the written interpretation of the x-ray or to the x-ray images themselves. A doctor can easily view a consultant’s note and recommendation or review the nurse notes. EMRs also “autopopulate” certain items. A nurse can enter vital signs under the vital sign section. Those vitals will then appear in several sections of the record at once; for example, on the quick view screen, on the nursing flowsheets, and on the physician’s daily note. There is no need for the nurse to type the same vital signs in three different areas of the chart

Although there are many benefits of electronic medical records, it isn’t all good. There are many aspects of EMRs and their implementation that can lead to patient harm.

Documenting in an EMR: Areas that can Cause Patient Harm

Copy and Paste/Carry Forward

EMRs give providers the ability to copy and paste their previous documentation into their current note. This may seem harmless and timesaving, but can lead to inaccurate notes, inaccurate data, and fraudulent activity. Issues with authorship and accuracy also arise when a provider copies and pastes another provider’s documentation. The copying provider must trust that the documentation by the original author is accurate. Also, by law, the EMR must clearly show the author of each entry. No matter what, even if the information was copied and pasted, when a provider signs a note, he/she is signing that the information contained in the note is true and accurate. They are responsible for the content of the note. Here are a few examples of bad things that can happen when EMRs are used inappropriately.

At the Eisen Law Firm, we are acutely attuned to the potential pitfalls of electronic medical records. We have found chart entries that were fraudulently copied and pasted, mistakes that were made because “alerts” weren’t set correctly, and boxes that were “checked” that did not reflect what actually transpired.

Allergies

Patients have been harmed and even died because allergies were not properly entered into the computer system. When an allergy is properly entered into the computer system, it should “autopopulate” to a “quick glance” screen, the physician ordering section, and the pharmacy.

This alerts all involved providers to the allergy.

Medication Reconciliation

Upon admission to a hospital, a member of the nursing staff typically is assigned to review all home medications with the patient for accuracy. Due to the EMR, any past medications that had been entered will appear, and the staff member is responsible for making any changes or additions. The same action is to be performed upon discharge, and there is to be clear documentation on the “discharge medication reconciliation” form about which hospital medications are to be stopped and which are to be continued after the patient leaves the facility.

The above examples are not primarily the fault of the EMR, but rather the user of the EMR. There is a saying, “garbage in, garbage out.” The EMR is only as good as the data put into it. However, there have been cases where EMR vendors have been sued because they falsely reported that they had “certified EMR” capabilities. In one case, the vendor (eClinicalWorks) paid $155 million dollars to settle allegations relating to false EMR certification.
(https://www.healthcareitnews.com/news/eclinicalworks-pay-155-million-settle-suit-alleging-it-faked-meaningful-use-certification)

EMR and Medical Malpractice

EMRs are used in lawsuits to provide information regarding what happened to a patient. EMRs are relied upon to represent what happened -- even several years later. Often, the electronic record is printed to a paper format and given to the patient when the patient requests their records. Although this provides some of the data in the EMR, it does not represent all the data available in the EMR. Moreover, the printed record lacks hyperlinks and other functionality that is contained in the EMR. For example, you cannot click on a printed page and view an x-ray. Often, thousands of paper pages are provided for review. Attorneys and experts must sift through the pages reorganize them to create a usable timeline regarding care and treatment. For example, the Cerner EMR prints the nurse notes by body system and not by date. Therefore, if the attorney wants to focus on one day’s nurse notes, they must review all the body systems for all the days to obtain data for one day.

Even with the shortcomings of the printed EMR, they are the certified data utilized to build a case. The data is taken from the EMR and placed into a timeline, often called a chronology. This can then give the attorney a clear picture of what happened to a patient and when. Often, when a medical record is given to the attorney by the defendant (produced), it is incomplete, and the attorney must request additional records. For example, the hospital may produce a medical record but may not include scanned documents.

Requesting Medical Records – The first step in a Medical Negligence Case

One of the first steps in a medical malpractice case is to request the medical record. The federal HITECH Act and applicable HIPAA laws allow a patient to request a copy of their medical records contained in the “designated record set.” Unfortunately, each particular facility gets to determine what is included in the designated record set. For example, billing records are often not included in this “designated record set.” Nevertheless, the designated set is typically the starting point for a record review. An experienced medical negligence attorney can review these records to see if your case has merit. After that, the attorney or a hired medical expert can determine whether there are additional records that need to be obtained.

The Electronic Medical Record is not new, but such records are becoming more pervasive and are continually developing more functions. They can be the key to your medical negligence case, so it is important to find a lawyer who understands how these records are maintained and retrieved.