Electronic health record (EHR) (also electronic medical record (EMR) or computerised patient record) is an evolving concept. It is a record in digital format that can be shared across different health care settings. EHR may include all the necessary information about a patient including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information.
Complete documentation and timely access to patient information become possible with the introduction of EHR and thus allows sound clinical decision making. Other advantages include reduced number of transcription errors, improved communication among providers, and less duplication of tests.
AdvertisementThe adoption of EHRs is unfolding fast. A varied and shifting landscape of medical liability risks and benefits can be expected along with the process. Whether these developments improve the performance of the medical liability system is not clearly known yet.
Implementing a new information system may initially bring up, rather than decrease, providers' malpractice risk. Increases in computer-related errors have been documented by several studies. EHR failure may be due to individual errors or bugs in the software systems.
Electronic documentation enhances the evidence available to evaluate claims and thus strengthen the accuracy of courts in determining liability. It is not clearly known at this stage of infancy how the law may evolve to allocate liability fairly among individual clinicians, EHR developers, and provider organizations that select and implement EHR systems.
Poorly designed EHR systems will definitely create a negative impact. Liability that arises due this should rest with those in control of system architecture and implementation, not end users. A sub-optimal design may set the stage for user errors. However in most contracts the developer is protected from liability arising from the use of the EHR system.
Such contractual provisions that immunize the system developer can be avoided. Organizations must invest attempt early to ensure that the EHR system is custom-made to the practice patterns of their clinical staff. Systems that are designed to minimize the risk of user error or misuse and maximize the ease of record retrieval may be selected. Another vital aspect to be taken care of is proper training of clinicians. Physicians must be willing to climb the learning curve. They should know how using EHRs may help protect them from liability, and how misuse or non-use may increase liability risk. Organisations should ensure appropriate practice conditions. Existing barriers to the optimal use of EHRs must be identified. This includes factors like the placement of computer terminals, problems accessing external records.
Physicians who function as experts in malpractice litigation can raise awareness among insurers and courts about the limitations of clinical-decision support systems and the appropriateness of departures from them in certain situations.
It is clear that EHR has long-run benefits but it is tough to quantify the risks and benefits with respect to liability. Provider organizations must however find ways to weigh the significant up-front cost and possible risks against the potentially healthy, but uncertain, long-run benefits.