How Reliable are your EHR Patient Notes?

A disturbing number of EHR issues and medical professional liability claims are based on serious problems with exam notes and other clinical documentation recorded in an EHR.  Regardless of the legitimacy of care and treatment, the inappropriate use of EHRs and/or EHR design vulnerabilities are exposing physicians to questions on the quality of care and physician due diligence.  Some key areas to consider follow:

Does Your EHR Present What Your Recorded?

With paper exam notes, the doctor and staff record information and the note reflects what they recorded.  Unfortunately, EHR based notes may not be as direct.

Why You Need a Clinical End of Day Procedure?

At the end of the working day, every healthcare organization performs a reconciliation of fee tickets and receipts to assure that all charges and payments were properly posted and applied.  This effort assures the integrity and accuracy of the financial records.  A similar process is needed to maintain and assure the integrity of your EHR based patient information.

Do You Know The Paper Chart to EHR Transition Risks?

I co-authored a case study on Medical Professional Liability (MPL) Risk with Susan Lieberman, Vice President of Risk Management for Conventus Inter-Insurance Exchange.  This case study highlights the importance of making good transition decisions as well as the substantial number of MPL Risks and, more importantly, risk reduction strategies you need to use to avoid serious problems in the future.

What are the Issues with Clinical Content?

Clinical content refers to the various checklists, documents, and forms that address an area of medicine when using an EHR.  For example, a pediatric practice would be interested in documentation tools for a newborn visit. Not all EHRs have clinical content for all areas of medicine.  For example, some EHRs have clinical content for internal medicine, but lack the details needed for dermatology or cardiology.

A disturbing number of practices have failed to analyze the clinical content of their EHR and are distributing exam documents and other information that do not adequately or accurately document patient care.  In the more serious situations, EHR clinical documents misrepresent the care provided and the patient’s condition.  For example, one practice was distributing exam notes that had inappropriate gender information for all patients.  In another situation, a specialist included extensive ROS information on the patient’s cardiovascular system which was not performed and not the specialist’s area of expertise.  Such problems could precipitate a wide array of care, insurance, and medical professional liability issues.

What MPL Issues are Associated with Meaningful Use (MU)?

Any transition of patient clinical records presents potential problems and issues that could affect medical professional liability (MPL).  Attainment of Meaningful Use is no different.

The Meaningful Use (MU) Criteria frames the use of a Certified EHR that enables a practice to qualify for the Medicare and Medicaid incentive payments.  Eligible Providers must fulfill 15 Core Measures and 5 of 10 Menu Set Measures to attain MU (For a complete list, go to https://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC-Core-and-MenuSet-Objectives.pdf ).  Many measures are associated with level of use based on a defined way of counting eligibility and usage.  For example, clinical summaries are to be provided for 50% of all office visits within 3 days of the visit to meet the clinical summary measure.

Your MU strategy should consider several MPL issues: