The U.S. Department of Health and Human Services has embarked on an ambitious mandate to require all health care providers receiving federal funds, including Medicare payments, to adopt electronic medical record systems.  This mandate has raised questions for healthcare providers and their patients.

Q:       What is the electronic medical record?

A:        Your electronic medical record (ERM) is the data related to your health care treatment, medications, x-rays, hospitalizations, operations, office visits, prescriptions, insurance payments and all other matters related to the health care delivered by health care providers anywhere in the United States.  This data is stored in a centralized electronic “folder,” and provides you and all your health care providers with information about who treated you, what treatment protocols were used and the results of your treatment, etc.

Q:       How is my EMR created?

A:          Your EMR is composed of one or more electronic files created by computers, electronic devices and software. Your healthcare provider enters your healthcare information and answers questions on a computer screen so the computer software can create and maintain your EMR.  All EMR software is certified to be “interoperable” so it can be read by all the computer systems of all U.S. healthcare providers. 

Q:       What are some advantages of having an EMR?

A:        The EMR allows you and all of your healthcare providers to have access to all of your healthcare information in one place. The goal of this increased availability is to improve diagnoses and patient care, and to provide a more standardized, empirically based treatment plan for your particular health conditions. 

The EMR keeps track of all medications patients take. EMR software can record the effects of prescriptions medications taken with over-the-counter herbal supplements, and can be updated as new drug interactions become known. For these reasons, the EMR should help healthcare providers to avoid prescribing medications that might cause serious complications for their patients.

Also, the EMR includes “follow-up” protocols that should help patients stick to their treatment plans. For example, if a doctor orders an MRI, the EMR system will route the MRI order to support personnel, who will then contact the patient to schedule the MRI.

Q:       What are some challenges associated with EMRs?

A:        Patient privacy and security measures have been built into the EMR software, but because so many people can access your EMR, security is a challenge. 

Accuracy is also a concern. Because the EMR is created, in part, by making selections from drop down menus, etc., some information appearing in the EMR may not have been written by the doctor, but by the software program in response to a checked box or clicked button. This “auto-population” can result in errors, such as the recording of procedures that were never actually done. Removing erroneous data from the EMR can also be difficult. Accuracy of EMR data also affects billing and insurance. The U.S. Department of Health and Human Services is trying to determine whether an increase in charges by health care providers using EMR is the result of fraud or improved accuracy and accountability.

The government is now studying the impact of EMR record accuracy on patient safety. It has been suggested that a new EMR patient safety agency similar to the National Safety Transportation Board that tracks the automobile safety.

Because “interoperability” has not yet been achieved, the various systems may not be able to “talk” to each other. This means that all your information may not be available in a single location to all health care providers.  

Standardization of care is also an issue. The EMR is created, in part, when your doctor chooses from a drop down menu of “best practices” based upon empirical data. The “best practices” are designed to help doctors choose treatment protocols that surveys have shown work best for the largest number of patients, but they also may reduce treatment options for patients who fall outside survey parameters.

This “Law You Can Use” column was provided by the Ohio State Bar Association. It was prepared by Donald A. Wochna, chief legal officer for Vestige Digital Investigations. Articles appearing in this column are intended to provide broad, general information about the law. Before applying this information to a specific legal problem, readers are urged to seek advice from an attorney.