Top 4 Attorney Concerns About Medical Records Part 4: The Electronic Medical Record.

By Tracy L. Liberatore Esq, PA

I find this to be the most interesting concern; the electronic medical record (EMR). I find it interesting because the electronic medical record was supposed to solve all the problems in the realm of medical charting and documentation, yet it brought with it a new set of unpredicted issues. Some might say the problems are worse than before the institution of the EMR. While the records are more legible and were implemented to decrease or eliminate medical errors due to inability to read orders, it seems the problem has simply evolved to form new issues for the medical providers and lawyers alike.

New Concerns- Provider Problems

Implementation of the EMR has increased physicians and hospitals ability to bill, yet provide little if any meaningful information.

Templates are created to automatically fill in information for physician and mid-level provider notes. While this helps reach higher billing levels, it muddies the waters for those trying to read the notes, figure out what is relevant, and what is part of a template. It creates massive amounts of pages in charts with duplicate, and sometimes incorrect, information. It replicates things such as past medical history, past surgical history and the like but does not ensure these populated areas are updated. Therefore old information may be contained in a note and new information not added. It also does not ensure that anyone reviews the patient’s history.

This especially becomes a problem if a patient seeks or receives treatment outside of a medical system using this type of charting. Suppose a patient developed an allergy that is not updated in a medical system. Suppose a careless overworked intake nurse does not ask the patient if there are any new allergies or additions to their medical record. This could lead to catastrophic medical errors and serious consequences for the patient.

Furthermore, the numerous checklists and pop up screens that were designed to protect patients may actually be working against this goal. The pop ups become so numerous that the provider goes on autopilot trying to complete their note and place orders. They begin to complacently click the “ok” button to continue charting. This, in turn, can lead to medical errors.

New Attorney Problems

Attorneys have problems navigating through the mountains of documents produced by these systems. It is hard to figure out where to look for documentation. Nursing notes, for example, could be entered in more than one part of the chart. Nurses can enter their own notes as a progress note, they can enter information into a flow chart, or into the medication administration record (MAR).

This leads to information being buried in the chart and requires a trained eye to discover.

There may be pages upon pages of duplicate information. Without checking for time stamps and provider entries, things are easily overlooked.

This could add to the inability to identify the absence of entries in a record or missing documents.

Checklists and templates make it difficult for the attorney to ascertain if certain areas of the body were actually examined or if the information simply was automatically inputted into the note due to the template.

Furthermore, records may be printed in random order, and require hours of sorting through to organize and ensure for completeness further compounding the difficulties for the attorney. This compounded with the lack or uniformity (discussed in a prior post) adds up to a huge problem for the poor attorney trying to navigate the mountains of medical records sent to them by a hospital or physician’s office.

Relax, We Can Help

This is where a trained medical professional can be of great assistance to the busy attorney.

A trained professional can save the attorney time and money by sorting through the mountains of medical records, determining what is relevant, duplicated, or missing, and advise the attorney how to proceed.

Someone who has worked with these types of records while clinically practicing can better understand what they are dealing with.

As the medical record system continues to evolve, it seems there will never be a uniform system in place. There are thousands of different programs available for physicians and hospitals to try and choose from when purchasing these systems. With the new legal regulations requiring the use of EMR’s to avoid financial penalties, EMR’s seem to be here to stay.

If you are having issues dealing with EMRs and need assistance organizing and deciphering what is going on, don’t continue to spend countless hours spinning your wheels trying to navigate these records alone. Hire a professional with experience to do this for you so you can focus on more important aspects of your cases!

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