Danger, Danger Will Robinson

As Electronic Medical Records mature, the legal community is getting the handle on how to use the volumes of data, timelines, and computer speak to win more cases.  Vulnerability is greater and more complex than in the paper world, as some unintended misrepresentation of the care given may be more hidden, and therefore not as evident to you, and therefore not as evident and open to inspection and correction.  The article EMRs can be costly in malpractice suits have the basic message in the title.

Some prominent points:

1. Lawyers are attending conferences on how to attack the electronic medical record
2. Losing lab and x-ray data through failures in tracking
3. Cut and paste was called "plagiarism" by the judge
4. Using auto-complete without confirming the information
5. Avoiding complex notes that are incoherent
6. Understanding the limitations of electronic signatures
7. Being careful with templates
8. Lack of individualized information about the particular patient
9. Gender confusion
10. Positive findings in 1 section noted negative in another section
11. Alert fatigue mistakes
12. Typos and large number of empty spaces

Clearly, the electronic health record is both a theoretically great solution and a minefield of potential legal issues.  It is important to keep this in mind when signing off on the EHR record of any patient, and to choose an EHR which helps you verify the correctness of the final data recorded.

The provider must never forget that the computer automatically captures the timeline of documentation in the document.  However, that recorded timeline may not accurately represent the sequence of care.  It is thus important to state the actual timeline (sequence, preferably with times) of clinical events in the clinical course of the medical decision making.  Many cases that go to trial hinge on a comparison of times between the records made by the physician, the nurses, the other staff, and yes, now, the computer.

Read the final output before signing.  A few words or sentences typed or dictated through voice-activated technology (e.g. Dragon) can insert meaning and coherence into an automatically synthesized notation that otherwise would read like "electric babble".  Read the nursing notes.  Explain any discrepancies.  Read that last sentence again. 
Acknowledge warning alerts and state in the record your medically appropriate decision, along with a brief summary of the basis for that decision. 

The cost and complications of the electronic health record will continue to rise until the process is simplified and designed for end-users.  It is going to get worse, before it gets better.