This blog post is a writing assignment for HIMT 1200: Legal Aspects of Healthcare, part of the Health Information Management Technology (HI13) Associate of Applied Science Degree program at Georgia Northwestern Technical College.
Electronic health record technology has existed for more than thirty years. The healthcare industry is steadily becoming more electronic, and more care providers are adopting electronic health records. Despite a multitude of advantages, electronic health records can lead to legal challenges (Gamble, 2012). These challenges can even partially be due to a system heavily reliant on precedent that lags behind the healthcare industry’s adoption of electronic health record technology (Sittig, 2011).
One challenge is inaccurate documentation, leading to an increased risk for medical errors and malpractice claims. Small mistakes that often go along with using technology are more likely. An example is misspelled or incorrect words due to overreliance on spellcheck (Gamble, 2012). Care providers can easily make mistakes in electronic health records if they use standardized entries. If the author forgets to make applicable changes to the template, the information in the record will be incorrect (Hammaker, 2020, p. 41). During the adoption period of an electronic health record system, errors also increase. (Gamble, 2012).
Another challenge is the susceptibility to fraud claims (Gamble, 2012). Complete and accurate documentation is the best defense against malpractice and fraud claims. Some courts adopt the use of inference of negligence regarding health record evidence. The court expects complete documentation to prove appropriate care. If documentation is incomplete or ambiguous, the court can infer the provider was negligent and purposely omitted the information that could incriminate him instead of requiring hard evidence. Due to this principle, even an ambiguous provider with no ill intent could still be prosecuted due to incomplete records (Hammaker, 2020, p. 40-41). With electronic health records, providers do not have an excuse for ambiguous documentation. The electronic health record provides the author with quick and easy tools to document service at the time of the encounter, and more information can be stored in the system to be easily accessed. The increased ability to have complete records that are so easily accessible could give the court more reason for inference of negligence when documentation is lacking or ambiguous.
Gamble, M. (2012, Jan. 30). 5 Legal Issues Surrounding Electronic Medical Records. Becker’s Hospital Review. https://www.beckershospitalreview.com/legal-regulatory-issues/5-legal-issues-surrounding-electronic-medical-records.html
Hammaker, D. K. (2020). Health Records and the Law. (5th ed.). Burlington, MA: Jones & Bartlett Learning.
Sittig, D. F. and Singh, H. (2011, April). Legal, Ethical, and Financial Dilemmas in Electronic Health Record Adoption and Use. NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065078/
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