Electronic medical records (EMRs) produce new—and sometimes confusing and voluminous—documentation. Understanding the implications of the transition from paper to electronic record, both generally and specifically, helps you make sense of all of this information. Consider the degree to which medical records have changed in the last decade. EMRs are becoming commonplace, and they're facilitating increased oversight of medical care. The tedious task of reviewing paper medical records stands in stark contrast to the ease of an electronic audit. As a result, medical care providers recognize gaps in care sooner, and dangerous patterns no longer go unnoticed.
In New Jersey, electronic medical records provided evidence that helped end a 16-year killing spree by Charles Cullen, RN. The hospital where Cullen worked used a computerized drug cart system. He left a trail by accessing the records of patients to which he was not assigned. The drug cart showed he was obtaining medications the patients had not been prescribed; one of these was Digoxin. Charles used these medications to kill patients, and a pattern of overdoses became obvious.
The executive director of a poison control center alerted the hospital administration to the suspicious pattern. By the time the hospital responded, Cullen had killed another five patients and had attempted to kill a sixth. The medical center alerted the state authorities and Cullen was fired. He was subsequently charged in several patients’ deaths, and he was eventually sentenced to 7 life sentences.
In an age when patient records are transitioning into an instantly searchable format, the legal community is, in many ways, gaining a sharper tool for their arsenal.
Pros & Cons of Electronic Medical Records
In a nutshell: EMRs are efficient. EMRs sharing medical information fast and efficient. A unified system within a hospital system or medical complex enables providers to access data and efficiently organize and sort information.
A healthcare system may leverage EMRs to help control costs. For example: The hospital medical staff can modify their order options, removing a more expensive treatment.
EMRs also augment physician access to records, streamlining communication. Professionals within a healthcare system can obtain information from a remote site; a primary care physician can access emergency department records from her office.
There is often a reduction in redundant charting when utilizing an EMR. The healthcare provider may enter data in one place at one point, such as an allergy. That data will populate throughout the medical record and save time for future providers.
Some patient record systems collect data from bedside monitors, lab equipment and other medical devices. This is incorporated into the patient’s medical record, saving time and ensuring more accurate patient information.
Improved Quality of Information
Electronic medical records systems include increased functionality that facilitates better patient care. For example: A physician may order the removal of a Foley catheter on a specific date after surgery. Something simple, like adding an electronic reminder for such removals led one facility to an 80% reduction in excessive hospital days due to infections. The staff routinely entered the reminder to remove 48 hours after the catheter was inserted, ensuring timely removal and a decrease in infection rates.
Another obvious qualitative improvement: legibility. We've all struggled to read handwritten records. Typed records help rid some of the aggravating and risky analysis of handwritten orders or documentation.
Fewer Medical Errors
Avoidance of medical errors is another potential benefit of EMRs. A system can be designed to supply data from laboratory systems, for example, that would alert a physician who prescribes a medication that's contraindicated because of, say, declining kidney or liver function, or other prescribed medication.
EMRs may also incorporate standards of care to remind providers to document required data. This ensures thorough patient information and encourages future continuity of care.
EMRs restrict access to certain parts of the medical record based on provider responsibility. Each EMR entry is tracked to a specific person, so anyone with access can read patient notes and know who authored them; that’s a real advantage when it comes to interpreting medical records. This assumes, of course, that each provider signs in with the appropriate user name and password.
Unfortunately, EMRs can spread inaccurate information. Any misinformation will be auto-populated throughout a record. For example; An inaccurate birth date becomes embedded in the record; a physician documents something inaccurate in the history and physical; a consultant echoes what’s in the history and physical and the information gets perpetuated. It's possible for misinformation to be repeated in a paper record, but duplication of incorrect data is much more likely in a computerized system.
One common lament in our increasingly computerized daily operations is the computer crash. Data can be lost during downtime at tremendous cost to the organization that's trying to reconstruct it.
A lot of people have grave concerns about privacy and security issues related to EMRs. You may have read of medical records that were lost, hacked or stolen. In an age of identity theft and massive data breaches, EMRs put patients and providers at risk.
The operational issues that affect the development and implementation of computerized medical records can reinforce provider roles. For example: A physician may be required to do a medication reconciliation. While this has always been the responsibility of the physician, in some settings nurses and pharmacists have assumed responsibility for what should be a physician task. An EMR can be set up to force a physician to perform that work.
Another issue is the old adage of “garbage in, garbage out.” We have a tendency to think that just because it’s in the computer, it’s going to be accurate. Legal nurse consultants and attorneys know that’s not the case. We are familiar with situations where people have unquestioningly followed misinformation in the medical record, and turned off the critical thinking part of their brain. Medical providers who rely on computers to do their thinking for them put patients at risk.
Understanding the pros and cons of electronic medical records equips the legal community to recognize potential pitfalls in patient care. Working alongside a Legal Nurse Consultant increases your awareness and gives you an added tool in your arsenal. LNCs help legal teams deliver the best possible client outcome by leveraging each team member's specific expertise.