Using Electronic Health Records (EHRs) can be an excellent way for medical professionals and their staff members to care of patients more easily, sending and receiving information when seconds matter in making medical decisions. However, there are also some serious considerations with EHRs, and one of those main considerations is culpability. Specifically, the question becomes who is culpable when something goes wrong. Is the onus on the medical staff to catch mistakes, or is it on the EHR system and the company that designs and manages that system to catch mistakes before they reach the medical staff?

The EHRs and the Companies That Create Them

The EHRs themselves are tools that can be used to make sure patients get what they need from their medical treatment. These records are much easier for medical personnel to use than paper records because they grant fast access to everything they need to know about a patient. When medical treatment is needed quickly, or when a specialist is consulted and results make a big difference in treatment, being able to send and receive records almost instantaneously can be highly valuable. The EHR companies know this, but they also know that they have to get things right. If their record software doesn’t work, patients’ lives can be at risk.

The Medical Staff and Their Use of Electronic Health Records

Medical staff who are switching over from paper records to EHRs can and do make mistakes. While medical information is rarely relatable in multiple choice verbiage, many of the EHR systems work off of dropdown menu options. Often times, healthcare professionals are forced to choose the closest answer, leaving room for misinformation and misinterpretations that can cause serious medical mistakes. Day-to-day typos and mistakes made in copying and pasting dates, dosages, and other patient information into EHRs are also possible. While these kinds of problems can happen to anyone no matter how long they have been using EHRs, people who are adapting to a new way of storing, using, and retrieving patient information are most likely to end up with errors. The culpability of the medical staff has to be considered carefully, because patients generally focus on the medical staff when issues appear. The idea that a patient would blame the EHR company for medical record errors is generally unlikely, and the medical staff would be the target of accusations, lawsuits, and related concerns.

The Health Insurance Portability and Accountability Act (HIPAA) affirms that the healthcare provider is the entity solely responsible for maintaining the integrity of the medical record, basically leaving the EHR vendor, consultant and systems integrator off the hook.  Further, many EMR vendors include clauses in their contracts charging the physician with the responsibility to ascertain proper use and maintenance of the chosen EHR system.

Medical mistakes and malpractice issues can come about quickly, and those issues don’t have to be just related to a procedure. These kinds of concerns can also stem from HIPAA violations, incorrect recordkeeping, mishandled information, and similar topics. One inherent issue with electronic records in general is that they can experience connectivity problems, system crashes, and security breaches, leading to total shut down of a facilities health information system, as experienced by the Washington Medical Center MedStar Health, Inc. network in March 2016.

An additional patient complaint about EHRs is the perception that medical staff have an easier opportunity to falsify, manipulate, or even delete records that prove crucial in a medical malpractice case.  Because of this, some courts question the validity of EHRs and can require that the records be tested before they are viable in court. Due to the relatively new technology that EHRs offer, courts have not yet had time to determine who may be at fault when patients bring a lawsuit based on EHR mistakes or misuse. Until more time has passed and more attorneys and courts have worked through patient concerns regarding EHR, culpability may not become completely clear.

An available option to help persons determine the integrity of their records in litigation is for the attorney to request an EHR audit trail.  An EHR audit trail is a record detailing when a computer system was accessed, who accessed the system and what operations were performed.  Simply put, the most common audit trail function is access management.  Audit trails are also used for tracking the behavior of persons who access the EHR system, identifying computer failure sites and times to allow for data reconstruction, reviewing a systems ability to perform its functions (e.g., overload detection) and scanning for external intrusions of those unauthorized to enter organizational databases.

The Importance of Culpability

Culpability is extremely valuable and important in the medical and legal fields. The risk for lawsuits and other problems is high for doctors and their staff members. In a medical malpractice lawsuit, it’s crucial to sort through a patient’s electronic medical records in an efficient and reliable way in order to ensure your cases’ success. For patients who feel that they were treated unfairly or that their medical or personal information was compromised, understanding who may be responsible and liable is important.

Should Changes Be Made to the Current System?

Whether changes need to be made to the system is a discussion that’s still up for debate. EHR companies don’t want the culpability for potential misuse of their products. In turn, the medical professionals and staff want to be able to trust the tools they use. Clear-cut, direct culpability cannot really be determined for EHR, mostly because there are definitely two sides to the issue. That is why many insurers and attorneys are choosing to utilize the assistance of legal nurse consultants. Legal nurse consultants have the expertise needed to research and sort through these complicated records, find missing information and decipher errors in order to help define a case’s direction and probable outcome.

ALN Consulting’s team of expert nurse consultants are trained to spot inconsistencies in medical records, and can help you identify culpability. Contact us today with a request to review your case records.