Electronic Medical Records: 18 Ways to Reduce Legal Risks

Carolyn Buppert, NP, JD

Disclosures

January 13, 2010

The Move to Electronic Medical Records

Both the current and former presidents have heralded electronic medical records (EMR) as a way to avoid medical mistakes, reduce costs, and improve care. EMRs do offer safeguards and efficiencies. However, the technology brings a new set of risks to the table, and, EMRs do not eliminate a significant set of risks that are present whether one uses the pen or the keyboard.

The benefits of EMR include immediate access to records, improved legibility, standardized documentation when using templates, built-in safety mechanisms, and clinical decision support. The likelihood that clinicians will be faced with the risky business of conducting a visit without a patient record, that pharmacists, auditors, and other clinicians will be hampered by sloppy handwriting, or that clinicians will prescribe a medication that the patient is allergic to will be reduced.

On the other hand, EMRs may generate new calamities. For example, some clinicians will be sloppy typists, just as some clinicians have bad penmanship. Malpractice defense may be hampered by an overabundance of meaningless documentation generated by the use of templates. Insurance auditors may doubt the veracity of documentation when, because of thoughtless use of templates, 15 of 17 records they requested look essentially the same. Furthermore, patient confidentiality (Health Insurance Portability and Accountability Act [HIPAA]) issues are raised when clinicians take medical records out of the office on laptops or thumb drives.

A clinician who has knowledge of and pays attention to these risks can decrease the chances of EMR-related mishaps. This article describes the risks and offers suggestions for reducing the risks.

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