Analyzing and reviewing digital medical data for litigation purposes

Analyzing and Reviewing Digital Medical Data for Litigation Purposes EHR data can serve as vital evidence in medical litigation. Here we look at the nature of evidence offered by EHRs during a medical record review.

The use of electronic health records (EHR), also called electronic medical records (EMR), has been a mildly controversial topic for various reasons. However, patient records are vital documents for a medical practice and anything that enables their efficient storage and management has to be welcomed. When it comes to medical record review for medical litigation, the documentation in these healthcare records assumes great significance. Whether paper-based or electronic, medical records have to be accurate if one is to ensure judicious decision making.

Despite Issues, EMRs Are Vital While supporters of electronic health records believe these can increase efficiency, bring down costs and ensure accuracy of records maintained, those against the system believe that the complexity of the user interface can cause medical errors.

They also claim that the idea behind these systems is improved insurance reimbursement and medical billing rather than affordability and efficiency. However, what everyone would agree upon is that the data in electronic medical records can serve as vital evidence in medical litigation.

A Major Drawback Here’s a description of what constitutes one of the major drawbacks of the EHR system. The process of entering information about the treatment provided to a patient is fairly straightforward. It includes check boxes, boxes to write notes, and drop-down lists. There are also pop-ups for warnings such as differential diagnoses, reactions between medications, etc. These inputs by the doctor are then combined with resultant data generated by the system. This information is displayed through the user interface on the computer screen. But that is, kind of, where the straightforwardness ends.

Once the request for medical records is sent, the data that comes printed from the system does not clearly reveal how the medical providers interacted with the

software while entering the data. The EMR system is set to provide only a fixed kind of information through a printout, which makes it difficult for the receiver of the information to know the total extent of the available treatment history of the patient and to verify the genuineness of the information presented in the printout.

Importance of Audit Trails Only audit trails could enable verification and better understanding of the information presented in an EHR printout. For attorneys involved in medical malpractice litigation, conducting audit trails might require the presence of an EHR expert who knows the software and, most importantly, how to phrase discovery requests and decipher audit trails.

The audit trail functions like an activity log that reveals what data inputs were made and changed by a user, and the time they were made. It can also indicate whether the record was deleted from the chart of the patient or altered and when this was done. Importantly, this will give the attorney or investigator an indication of whether the entry was changed after an unfavorable outcome was discovered, or after the commencement of litigation.

Intelligent EHR Systems There are also EHR systems that can create logs of audit trail entries whenever someone opens or even views a patient record which can give an inclination of whether a physician or some medical professional reviewed the results of a scan or diagnosis. That’s why it is important for a healthcare practice to get the most efficient EHR system.

Medical Review Services to Extract Vital Evidence A medical review company understands the importance of organized medical records and offers value-added services such as medical records indexing, organizing and sorting services. When the electronic medical records are organized systematically, the reviewer can quickly and easily review the documents. Reliable medical record review services help to reduce the time a reviewer spends on case evaluation.

Getting the Right Electronic Health Record System Indeed, the electronic health records field is growing astronomically in healthcare.

There is also a maze of products out there which makes it quite confusing for physicians, who may not always be technically astute, to come up with the right choice. In spite of the presence of so many products there isn’t a single system that can function as an overall solution. Since each healthcare practice is different and has unique challenges, a significant amount of effort must be put in to find the right solution.

Scalability, compatibility, features and upgrades, information portability, and, of course, cost are vital parameters that must be considered to decide on the right electronic medical record system. It could save the reputation of the practice or physician some day.