Would your electronic medical record hold up in court?

November 7, 2008

This question is being asked increasingly often as more physicians go electronic, according to American Medical News (10/13/08). Federal Rules of Civil Procedure, approved by the US Supreme Court in December 2006, not only make electronically stored data discoverable in a trial but render physicians vulnerable to several new liabilities inherent in the detail electronic data provide.

This question is being asked increasingly often as more physicians go electronic, according to American Medical News (10/13/08). Federal Rules of Civil Procedure, approved by the US Supreme Court in December 2006, not only make electronically stored data discoverable in a trial but render physicians vulnerable to several new liabilities inherent in the detail electronic data provide.

If a nurse records information under a physician’s login and password and that information is incorrect, for example, the physician could be held liable. To avoid such a situation, you need a system where the record keeping coordinates with a record of who entered what when (the record’s metadata) to provide an accurate picture.

To protect yourself legally, the first step is to use an electronic medical record (EMR) that is certified by the Certification Commission for Healthcare Information Technology (CCHIT). The US Department of Health and Human Services contracted CCHIT in 2005 to further widespread EMR adoption, and the commission released its first set of certification criteria in 2006. But because certification criteria continue to evolve, physicians still must practice due diligence in deciding on a system. When shopping for a EMR that will hold up in court, consider how well the system meets these criteria:

[] Shows authorship by clearly indicating who entered what portion of the record

[] Deals clearly and comprehensively with changes by tracking alterations to the record as well as who made each change and when and saves the original

[] Has an audit function that supports the accuracy and validity of the record and has cross-checks