EHRs: Can you practice without them?
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Benefits to Physicians Using Electronic Health Records and Other Safety-Enhancing Technologies To be successful in this emerging era of value-driven health care, physicians will need to embrace the following functionalities of EHRs and other safety-enhancing technologies:   Improved aggregation, analysis and communication of patient level information -- permitting the consideration of all aspects of a patient’s condition prior to making diagnoses, or decisions to hospitalize, discharge or to obtain additional tests, procedures or consultations;   Diagnostic decision support -- providing instantaneously accessible results from laboratory, radiology and pathology, as well as procedures and consultations from a wide range of sources;   Therapeutic decision support -- integrating EHRs which have been certified by the Certification Commission for Healthcare Information Technology (CCHIT) with the best evidence-based clinical decision support systems to ensure the delivery of the most appropriate therapies;   Prevention of adverse events -- by building in guards against prescribing drugs and other treatments, which, based on patients’ current medications, lab results, kidney function, body weight, age, allergies and other factors captured in the electronic database, could result in adverse events, preventable injuries and the medical legal basis for possible litigation;   The employment of clinical alerts and reminders -- providing the latest indicated screening tests to detect life-threatening conditions in early, treatable forms or adequately monitoring chronic ailments to prevent their complications; and   The use of the electronic record for clinical quality improvement research -- to keep ahead of the ever-increasing standard of care by electronically capturing, monitoring, evaluating and improving clinical practices continuously. (Couch, J.B, CCHIT Certified Electronic Health Records and other Safety Enhancing Technologies: Medical Legal Risk Management Benefits, Pitfalls and Safeguards; CCHIT; Chicago, 2007) at http://www.cchit.org   Some Risks in Using Electronic Health Records and How to Avoid Them In addition to the benefits of using EHRs, there are also some definite risks.  The following section will introduce those as well as some safeguards for avoiding them.   Some of these risks (and potential safeguards) include:   New federal rules permitting the broad discoverability of electronic records in legal actions, which were recently adopted by New Jersey.  In general, EHRs are to be treated as “business records” so that they are admissible in legal actions under the business records exception to discoverability. Some exceptions to discoverability include those reproduced for infection control and other peer review committee meetings, draft electronic documents (e.g. e-mail, voice mail, e-annotations, instant messages, etc. and personal health records or PHRs).   When drafting policies and procedures for the EHR, some areas need special attention if the electronic record is to be defined as the legal health record for a patient…  For example, cutting, copying and pasting may be efficient for the clinician, but there are risks associated with it. The note may go into the wrong patient’s chart. If another person composed the original entry, the original author may object to having her written material used without knowledge or permission. Before organizations create a policy on cutting, copying and pasting, they should investigate limitations of the technology to ensure software compatibility and avoid the production of unreadable notes.  Quinsey, CA, Policies and Procedures for a Legal EHR; Journal of AHIMA; 78(4):62-63 (April, 2007)   Similarly, organizations’ policies should detail how digital photographs and videotapes concerning a patient’s condition are to be stored for safekeeping or disclosed. In addition, all verbal orders will be accurately time- and date- stamped, making it clear when, according to federal and state laws and accreditation requirements, they need to be signed. Finally, there must be policies for physicians to electronically acknowledge their review of test results, which guide their clinical decisions (see below). Quinsey, CA, Policies and Procedures for a Legal EHR; Journal of AHIMA; 78(4): 62-63 (April, 2007).         Easily demonstrable deviations from best evidence based practices, especially when physicians delete, change or otherwise ignore these safety features. Doing so may produce an easily discoverable audit trail for a plaintiff’s attorney in cases arising from failing to respond to clinical alerts or easily accessible best practice guidelines (see the preceding section of this article for these and other features of certified electronic health records). According to Marilyn Lamar, Esq., a leading healthcare IT attorney, to minimize this risk, physicians must be able to use electronic systems that permit them to document their rationale for not taking into account available online data, provide prompts to discuss certain information with patients at every visit, and to periodically review and read just the controls on these alerts and those warning of potential adverse reactions. This, she says, will avoid building up a discoverable electronic record documenting the ignoring of these risks.    Physicians need to know how to use their electronic systems as a justifiable shield against unwarranted medical liability claims. They need to document their clinical rationale for not following alerts or tamping down their sensitivity.  Electronic health records must have required prompts for physicians to justify clinically their overriding of alerts or practice guidelines.      Physicians also need to be able to use the graphics capabilities of electronic health records illustrating patient care results to document the effectiveness of the care provided and justify the subsequent clinical decisions made or not made. All of these features need to be available in electronic health records (Cf. Couch citation, above).   Inappropriate altering of electronic health records, which, as with paper records, could raise the issue of a potential “cover up” (that can be even worse legally for defendant physicians than their underlying negligence, if any even exists). According to Mark Leavitt, M.D., Ph.D., Chairman of the Certification Commission for Healthcare Information Technology (or CCHIT), the latest CCHIT-certified electronic health records “….have the capability to prepare an audit of who has accessed the medical record and the ability to ‘lock’ the record once it is created, not allowing an alteration of the record without leaving a record of the alteration.” This feature of certified electronic health records should provide an opportunity to physicians needing to alter a medical record to justify a clinical course of action subsequently taken, providing a more defensible record (see Couch citation, above).