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Navigating Advantages and Pitfalls in Patient Care Documentation
Electronic medical records (EMRs) are increasingly used to document the delivery of patient care. Clinical practices that participate in medical education are more likely to employ EMRs. Yet, the growing use of EMRs presents a new set of challenges for not only medical education but also legal professionals.
EMRs bring advantages, but they also pose certain challenges for physicians making the transition from paper to electronic records. There are certain legal implications involved with EMRs that medical providers need to be wary of.
It’s no secret that technology, although it provides convenience, also introduces errors and malfunctions if systems are failing.
Any software is vulnerable to bugs and shortcomings that may prove costly. Though EMR software is believed to have the capability of reducing medical errors, the opposite is sometimes true. Studies show that popular computerized physician order entry systems are susceptible to many types of medication error risks.
Reports of pharmacy inventory displays mistaken for dosage guidelines, order entry display screens that prevent a clear view of the prescribed medications, rigid ordering formats that produce wrong orders and more. Physicians’ tendency to copy-paste patient data can result in mistakes that get repeated across various data forms. This simple copy-paste function of the EMR also creates problems regarding authorship when a medical record is investigated for legal purposes. Other issues include the risk of viruses, bugs, and technological glitches.
Researchers at Johns Hopkins conducted a comprehensive study in 2016 of medical errors in the U.S. They found that an average of 250,000 people die because of medical mistakes each year.
Strategies for Legal Preparedness
EMRs can have an impact on medical malpractice litigation by increasing the availability of documentation and facts that can either prove or defend a malpractice claim. EMR data that comprise every single electronic transaction including timestamps of clinical activity, input of orders, etc., are discoverable in civil trials. This can very well increase the possibility of prosecutors discovering evidence of malpractice among a team of providers.
According to UpGuard, there were 642 reported data breaches involving more than five hundred medical records in 2020. In 2021, this number increased to 714 data breach reports involving five hundred or more medical records, an average of 1.95 data breach reports per day.
Data breach following unauthorized access to protected health information is another vulnerability of EMRs. HIPAA violation penalties are remarkably high for data breaches that occur.
Physicians and other members in a clinical team can be provided training in a private environment, which is often more useful and effective. In hospitals, there should be cooperation between the hospital’s IT department and physicians.
Attorneys should also make sure to educate and counsel their clients who are either patients or medical professionals on the penalties of EMRs, and how to make sure to stay aligned within legal rights and ethics.
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