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.
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.
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
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.
Labels: electronic medical records, health care, U.S. Department of Health and Human Services