Ralph Sitler III, JD--Many areas of industry welcome new technology with open arms, especially the medical field. Physicians and other health care professionals are always trying to find new and intrepid ways to improve patient care, increase efficiency, and boost the bottom line. However, there are often new risks associated with adopting new technology. This article aims to make physicians aware of some of these risks and help avoid potential legal issues concerning use of EMRs.
It has not been determined whether implementation of an EMR makes the incidence of medical malpractice claims rise or fall. However, doctors must be cognizant of the new frontiers and avenues of litigation that may present themselves with EMR implementation.
Liability for errors stemming from clinical advice or missed contraindications from the EMR software will likely fall on the doctor’s shoulders, not the EMR’s, if a problem were to arise. Most EMR contracts limit liability for their products, thus making the doctor ultimately responsible for any errors made as a result of using the EMR. Doctors must remember that the EMR is only one tool in their large medical toolbox, one that needs to be used with all the other resources and knowledge available to the doctor. EMRs should not be used as a crutch on which to base clinical decisions. Such an approach can prove fatal to the health of a physician’s practice.
Errors can also occur as a result of using software, such as inflexible forms that the EMR has you fill out or the unfamiliar layout of patient charts. This can lead to misreading a patient’s previous history and symptoms, or incorrectly noting which medications they take or are allergic to. EMRs also have the potential for programming bugs and viruses, something that no doctor in history has had to be concerned about before the introduction of technology in the office. Understanding these limitations will also aid in the proper implementation of EMRs in any practice.
Finally, the issue of cloned notes has been identified by the Office of Inspector General as an area of concern in their 2012 Work Plan. A cloned note is a note that appears identical across many patients or services. Doctors have long used mental rubrics in their mind when making notes, cognizant that their notes will aid in CPT documentation down the road. However, EMRs can take this a step further, producing a standard-form note for each condition. The drawback to this is that it can appear to remove the diagnostic process that every doctor must demonstrate when evaluating patients. Auditors could then challenge the note, possibly making it difficult to receive payment for the service rendered.
Keep these issues in mind when deciding whether an EMR is right for you or when using your current EMR. This will help keep you and your practice ahead of the game when it comes to the legal issues that surround technology, especially EMRs.
