Electronic medical records: friends or foes?

Hypothetical: A medical malpractice lawsuit alleges a failure to diagnose the aortic dissection that caused the sudden death of the patient. Two days before his death, the patient had visited a medical clinic, where the patient had shown normal vital signs except for a slight fever, and a mild shortness of breath. Based on the initial clinical presentation, the tentative diagnosis was pericardial rub or possible systolic murmur. The clinic’s electronic medical records (EMR) showed that the clinic had promptly ordered blood work, a blood culture, and an echocardiogram, with a follow-up appointment in one week. Benefits of EMR. EMR are becoming more and more common for health care providers. Providers are recognizing that EMR offer many advantages over handwritten records. They can be accessed quickly and easily by multiple providers at different locations. A provider can obtain all types of medical information (e.g., chart notes, test results, pharmacy records, and radiographs) from a single access point. Some EMR systems provide cross-checks for error reduction, such as notifying the provider regarding possible drug interactions. EMR systems may also prompt the provider and office staff to document follow-up after a patient appointment, such as documenting review of test results or radiographs, follow-up notification to the patient, and scheduling of any additional appointments. EMR are more legible and safer from destruction. EMR systems can protect confidentiality by password access and other appropriate safeguards quite well. EMR are searchable by content, both for use for patient care and for appropriate research purposes. They can result in cost reduction by reducing paperwork. Some systems also allow for patients to view their medical records directly via online access. Litigation with EMR Production of records. Certain features of EMR deserve special attention from a litigation perspective. As an initial matter, providers using EMR need to consider how records will be produced for litigation. Production of an EMR patient record takes more careful consideration than merely making a photocopy of the chart and duplicates of any radiographs. Legal counsel and the health care provider will likely work with in-house IT staff or IT consultants to determine how to access and produce the EMR correctly.