Last year I was at St. Lukes Hospital in Houston while a member of my family had surgery and recently I was in the same position.
We are constantly getting records on behalf of clients and reviewing them. We frequently retain the services on Information technology specialists to assist in reviewing the records. We have found that while electronic medical records can function well there are many potential problems, lacks of communication and the tantalizing temptation to alter the medical record by going back in and “amending prior entries”.
At St. Lukes each of the time a member of the staff came into the room they did so with a mobile computer on a platform so that they could make immediate entries into the patients’s chart. Each different discipline would come in and make their entries, and then leave. Reviewing a record such as this after the fact finds that the entries end up being departmentalized, that is each department will have its own section and all the records from that section are together. However care is not supplied in that manner. Care is supplied on a given day by different individuals and the requirement then is that we breakdown the record so that we can see all of the events that occurred on a given day and in chronological order for that day.
Therefore in analyzing the record we will ask a paralegal to go through the record and find every entry for a given day or days when we know the problem occurred. Then when we have the multiple pages from different sections of the chart we re-organize the data into daily events so that they can be reviewed by us and by any expert we select so that we can actually see what the patient was dealing with on a minute by minute basis. Once we are aware of what occurred we can then identify gaps or errors that occurred.
In my own experience I was able to observe the ability of the internist to access, real time the laboratory results as they were posted, the surgeon the radiology reports as they were posted and the ability to communicate among each other in the decision making process. The information was immediately available and usable. I also noted the pressure that they were all under to see a patient, get tests performed and decisions made so that they could proceed to the next patient. No problems on my end but it brought home the challenges that our clients face and our approach to record review.
In a recent case we obtained the meta data associated with the records. This data allows us to see when each entry was made and whether or not there were any returns to a particular entry, This would indicate a change and an inappropriate alteration.
Knowing how the records are entered it is obvious that so much information is being entered that it will be impossible for any individual in charge of a case to keep up with all the information being entered. Currently there is no way to for the practitioner to be able to differentiate between “information” and “important information” and to know when “important information” is being entered into the chart. Records are replacing the oral communication necessary to optimize treatment. The excuse is that “I entered the information in the record so that it was available for the surgeon to review.” How was the surgeon supposed to know it was there?
It was noted in both instances that at times it became more important to enter information than know the importance of the information being entered. The clutter of information precluded the practitioner from being able to be aware of the problems and being able to react to that information in a timely fashion.
Our record reviews will not change. We will continue to break down the information into a minute by minute analysis, a day by day analysis or as in most nursing home cases, a week by week analysis. However, we now have another tool. We can check to make sure that the entries were made when the record says they were entered. It will be easier to pick up changed records and give clearer copies to present to juries. We will be able to see when an individual accessed the records and when that crucial information was known,
EHR will improve medical care. EHR will allow us to better represent you.
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