Your EHR Is Watching You

Document, document, document. This is the mantra you follow carefully in creating your medical records to ensure good patient care, to support billing — and to provide a defense if you ever face litigation.

Regarding the latter, it bears to keep this in mind: Your electronic medical record (EHR) is doing some documenting of its own. EHRs record metadata — that’s data about data — that show when and how you use the software.

“All physician interaction with an EHR is time-tracked and discoverable [in a lawsuit],” writes David B. Troxel, MD, author of a new study by The Doctors Company, a professional liability insurer, of the company’s completed claims.

The study looked at EHRs as a contributing factor to medical liability claims. Although only 1.6 percent of the claims studied had EHR-contributing factors, the project revealed the pace of these claims has grown over the past 10 years, from a low of two cases from 2007 to 2010 to 66 cases from July 2014 to December 2016, the dates of the new study.

Consider the anesthesiologist who was sued in a 2002 case over a bad outcome after surgery. As reported in Emergency Physicians Monthly in 2011, “Prosecutors ho[m]ed in on the anesthesiologist[’s] spotty logging of vital signs during the procedure and asked for the metadata. That’s when they learned he had attested to being present for the full operation … before it had concluded. Even though he had stuck around the whole time (it turns out these early attestations were common practice at his hospital) the metadata made him look dishonest. He ended up settling the case.”

Your EHR’s metadata will reveal such activity as:

  • What information you’ve reviewed and for how long, such as hospital records, consultant reports, lab results, and the like. Did you fail to look at a patient’s lab results? Spend just moments looking at a patient’s previous notes? “If patient injury results from a failure to access or make use of available patient information, the physician may be held liable,” Dr. Troxel wrote.
  • Your disabling or overriding of prompts or alerts, such as a drug-drug interaction alert. “If it can be shown that following an alert that was disabled would have prevented an adverse patient event … the physician may be found liable for failing to follow it,” Dr. Troxel wrote. Always document why you overrode a prompt, he advises.
  • What changes and additions you made to a record, and when. Always include the time of your interaction with the patient when you change or add notes after a patient encounter, to avoid any suggestion of false or inaccurate information, said Dr. Troxel — just like with paper medical records.

Conversely, metadata also can be your defense, supporting your actions, in litigation. Just remember as you navigate through your EHR that it “remembers” when and where you click.

Visit TMA’s Electronic Health Records webpage for more information about using an EHR in your practice. Are you thinking about switching to a new EHR product? TMA’s new publication, Switching EHR Systems, has great advice to help you make the right choice. Or, are you looking to tighten up your documentation habits? It may be time for a Coding and Documentation Review with TMA Practice Consulting. Contact a TMA consultant at (800) 523-8776 or[at]texmed[dot]org.

NOTICE: The Texas Medical Association provides this information with the express understanding that (1) no attorney-client relationship exists, (2) neither TMA nor its attorneys are engaged in providing legal advice, and (3) the information is of a general character. This is not a substitute for the advice of an attorney. While every effort is made to ensure that content is complete, accurate, and timely, TMA cannot guarantee the accuracy and totality of the information contained in this publication and assumes no legal responsibility for loss or damages resulting from the use of this content. You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be sought. Any legal forms are only provided for the use of physicians in consultation with their attorneys. Certain links provided with this information connect to websites maintained by third parties. TMA has no control over these websites or the information, goods, or services provided by third parties. TMA shall have no liability for any use or reliance by a user on these third-party websites.  

Published Oct. 30, 2017

Last Updated On

October 31, 2017

Originally Published On

October 30, 2017