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Understanding Transcription Errors and Metadata in Medical Malpractice Cases
In earlier decades, illegible handwriting, inaudible communications, and the time required to record patient notes manually restricted hospitals’ productivity, response times, and level of care. Now, electronic medical record (EMR) systems with speech-to-text dictation technologies, such as M Modal or Dragon, have undoubtedly become valuable tools that improve the efficiency of medical facilities. However, these systems also come with risks, as providers must look out for and correct transcription errors that can harm patients.
The term transcription error describes data incorrectly entered into an electronic healthcare system. According to Sheila Burgess, RN, RHIA, CDIP, CHTS-CP, director of CDI at Sutherland Global Healthcare Solutions, transcription errors in conjunction with medical dictation software or services typically occur due to misheard or unintelligible words, vague abbreviations and phrases, or haste on the part of medical professionals. For example, a physician dictating a progress note may intend to note their prescription of hydromorphone to a patient in their dictation, but the output reports “hydro morphine”. This is significant in a pharmacological sense because hydromorphone is approximately three to seven times more potent than morphine. The unintended consequence is a mismatch between the drug and dosage, which left unchecked may propagate amongst the clinicians reviewing the provider’s notes in providing care for the patient. The ultimate result could lead to the patient receiving an inappropriate medication or dose thereby reducing the quality of care.
Considering that the average time providers spend reading and reviewing transcriptions in patient notes is less than three seconds, it is evident how these seemingly minuscule errors slip past healthcare workers, resulting in potentially avoidable harm to patients and medical negligence liabilities for healthcare facilities and workers. Integrating electronic medical record data and provider dictation services is a common practice in the healthcare community which makes transcription errors relatively easy to identify during the course of care as well as in the context of a medical malpractice case.
Every healthcare institution is federally required to establish and follow particular guidelines for using EMR systems, 3rd party software and provide adequate training for users on expected use for each. Together, these guidelines and EMR metadata hold medical professionals accountable for satisfying the established standard of care, as the guidelines obligate clinicians to act ethically, and the metadata can reveal whether healthcare workers heeded their responsibilities. Thus, plaintiff and defendant counsel in medical malpractice cases would be prudent to be aware of healthcare organization’s policies on transcription and how to employ the metadata of electronic medical records to ensure deviations from policies and procedures have not occurred in the case.
Utilizing Audit Trails
In the course of medical malpractice cases, attorneys must be aware of provider expectations set by the dictation policy. Using this policy in conjunction with a comprehensive version of the patient’s medical record and a user access and event audit trail from the EMR system, attorneys can discern whether or not medical professionals followed protocol if a particular dictated note is called into question for accuracy. Metadata, or automatically generated data that provides information about other data, from the EMR audit trail can provide insights into recreating the provider’s actions surrounding the entire note creation process from a technical point of view in that it allows for extensive documentation of patient information and easily discoverable evidence. For example, metadata can be used to accurately calculate the length of time spent by a particular provider in a patient’s chart. Using the timestamps of an audit trail, an attorney can pinpoint the timing of a transcription entry, its review time, and approval time to validate or disprove a physician’s statement on time spent caring for a patient. Then, one can cross-reference these timestamps with hospital policies to verify if a clinician followed protocols for entering and reviewing patients’ notes in an appropriate manner.
Analyzing hospital policies and electronic medical record metadata together, even if it may not appear to be contextually relevant to the case, may prove crucial in proving medical negligence. As audit trails allow one to reconstruct a crime scene through technology, metadata makes it easier to defend or call into question the integrity of defendant statements during depositions.
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