Update on Electronic Health Records

Lancet Staff Report

As technology has greatly enhanced the efficiency of record keeping, it has also created a potential for malpractice claims. A report by the Florida Academy of Family Physicians (2010) presents a number of liability issues and suggestions for addressing them.

There are instances where liabilities begin with contractual arrangements with vendors or suppliers of technical services. Sometimes software does not identify conflicts in medicines that are prescribed for patients. In these cases malpractice carriers often do not provide indemnification. It is recommended that physicians do not sign agreements that hold harmless vendors or suppliers.

There may also be times when the physician may violate standards that are embedded in pre-set clinical requirements for prescriptions. Medical providers should be aware of practice guidelines and document when exceptions must be made.

It can be of great benefit for the physician to have a complete electronic record of his or her patients. A problem may arise in the physician knowing too much of the patient’s information. Knowledge of all of this information may expose the health care provider to potential malpractice claims. It does, obviously, require a great deal of time and effort for the doctor to review all of a record for reliability.

There may be instances where the quality of one physician may be questioned as a result of electronic information that may have been initiated by one or more previous providers. Incorrect information may be inadvertently passed from one provider to another. It is strongly suggested that physicians establish a policy that patient records are not to be copied and pasted.
Patients have long relied upon, and reported to others, the quality of bedside manner. While the computer can be a tremendous tool, patients rely on the personal manner of their doctor. When
entering data, it is recommended that doctors ask patients to verify information that is being entered.

Finally, the report points out that, even in this modern age, social media are not HIPPA compliant. Facebook or text messages of data entry may expose a physician to liability. Only secure portals should be used while documenting patient information. Even email attachments of medical reports should be encrypted where they can only be opened with a password that is sent in a separate email or communicated over the phone.

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