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Lawyers smell blood in electronic medical records

Lucas Mearian | April 14, 2015
Data governance is sorely lacking.

While his physicians claimed they'd documented his care properly, the EMR was so complex and filled with repetitive data, the judge found it in inadmissible. "When an electronic medical record is printed out, the amount of repetitive data in it is ridiculous," Klein said. "Attorneys are having conferences on how to attack EMRs.

"All these cases were from top vendors. We're talking about well-established ones used at Kaiser [Permanente], at the VA... and academic institutions," Klein continued. "These are not rare cases. These are common things."

In another case, the physician was accused of plagiarizing data entered from another healthcare provider because he copied and pasted basic patient information.

Rita Bowen, senior vice president of health information management for Healthport in Atlanta, a records audit management and tracking technology firm, said she's seen duplicate data, erroneous data and copied data in EMRs.

"I've seen records where someone has copied and pasted from older records, 'The IV will be removed today,' over and over again. Well, was it removed?" Bowen said, illustrating how admins may copy and paste older information into newer records.

In fact, when it comes to strong information governance, Bowen said most healthcare facilities are woefully behind in rolling out rules and standards and ensuring they're adhered to.

But the problem isn't solely human error. The way EMRs and electronic health records (EHRs) are designed can prompt error-prone entries. For example, drop down menus for diagnoses can automatically enter data if a mouse is hovered over them too long.

"We've seen 92-year-old women getting diagnosed as crack addicts because of drop down menus," she said.

While Klein and Bowen readily defend the implementation of EMRs and EHRs as both time savers and records that increase mobility and accuracy when used properly, vendors should also be working to reduce complexity and introduce safeguards.

For example, when data is copied and pasted from one page of a record to another, some EMRs highlight that entry until an attending physician or nurse has verified it.

 

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