The EMR (Electronic Medical Record,) or EHR (Electronic Health Record,) is a tool with an unquestioned love-hate relationship among both physicians and patients. It is a tool that has inserted itself in-between the most basic physician and patient relationship. It is simply accepted as necessary inconvenience.
Physicians have come to accept the limitations of these systems and learned to work around the cumbersome quirks as best they can. The penalty is falling behind schedule in a sea of never ending patients. With most patients having some level of access to their records electronically, there are often uncomfortable conversations about specific diagnosis and other terminology that patients may find judgmental or in some cases may even take offense. These are all issues that have been widely examined, discussed, debated and have motivated many companies to improve their products. These are not the problems that we see representing the biggest risk for physicians.
There is an old saying, "if you've done nothing wrong, you have nothing to worry about." Unfortunately, time and time again we see that this is not the case in medical board accusations. Your EMR may be creating a huge liability for you everyday you use it. What you may have come to accept as limitations of your EHR because of its template driven approach creates inaccuracies and misrepresentations that you will be held accountable for. Most physicians are surprised when they are presented with paper based versions of their electronic medical records. There are usually hundreds of pages, including details of exams and assessments, that the physician may be seeing for the first time.
Here are some of the issues we commonly see:
The takeaway is the criticality of reviewing and correcting clinical notes prior to signing reports. As time passes and those notes accumulate, the cumulative risk may present a large liability. Regular chart reviews and quality audits are essential. This is particularly true for all patients receiving controlled substance prescriptions.
We will continue to explore this topic in future articles. We will look at specific examples of medical board actions related to poor record keeping for patients receiving chronic opioid therapy. We will also explore recommendations for strategies to correct these issues, and in some cases, reconfigure the note features of specific EMR's.