Understanding Metadata or “Data about Data� in the EHR EHR benefits are welcomed by medical-legal entities including medical review companies. However, EHRs carry increased liability risk as well.
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The electronic health record or EHR, the present standard of documenting a patient’s care, is the detailed record of a patient’s entire care. The EHR has many advantages such as enabling improved access to patient data, coordination of care across multiple healthcare systems, ensuring improved patient safety, and also simplifying processes such as medical record retrieval and medical peer review. Since its implementation and use, the EHR has also become more user-friendly and customizable. However, the electronic health record does carry new liability risks for providers. The common problems associated with the EHR are erroneous data entry, failure to enter data, patient privacy issues, misunderstanding or misuse of the software, and generating metadata. EHRs come in different designs and liability can increase based on these designs. EHR templates could bring in data and assessments that may not have been adequately reviewed. The copy-paste issue is a real concern with EHRs and this tendency on the part of providers results in propagating errors in documentation. Mostly, EHRs allow only listing the diagnoses associated with a patient visit. The physician cannot document in detail his/her evaluation of the potential causes of the condition, which could prove risky if a malpractice issue arises. A major concern with EHR is metadata or data about data. EHR metadata shows how, when, and by whom the EHR data was received, created, accessed, and modified.EHR metadata could be relevant in medical liability lawsuits in that it could be valuable to a lawyer trying to prove a failure-to-monitor or delayed-diagnosis claim. The real risk arises when a physician facing a lawsuit tries to review the medical chart and clarify some important points. The metadata available in this regard will flag the physician’s activity as suspicious. EHRs are distinguished for their audit trail feature. This audit trail is metadata that records who, where, when, how and even why a person accessed a patient’s medical record. An audit trail or log is metadata that records information such as the identity of the user who accesses a patient’s medical record, the terminal/device used for access, the time of access, the action taken by the user such as viewing the record or modifying the record, the substance of content added to the record as well as any
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changes or corrections made by the user. The audit trail records only the person who is logged into the computer. Therefore, if an attending physician reviews the medical record along with a resident who is logged in, the audit trail will not record that an attending physician viewed the record. It is recommended that the attending physician should login separately to view the record or lab results to provide electronic evidence of his or her involvement in the care of the patient. In medical malpractice and personal injury cases, audit trail experts are hired to analyze metadata and provide any helpful information. An audit trail expert will identify alterations, modifications, or deletions in the medical record. Presence of such evidence could prove damaging to the physicians involved. Though the EHR's ability to generate templates for specific symptoms or diagnoses is commendable, copy-pasting can result in errors in data entry. If a physician discovers such errors, a “correction” should be made. This correction is a change made in the patient’s medical record during the routine treatment course, as Ryan M-L mentions in “Making changes to a medical record: corrections vs. alternations.” Such changes made before the issue of a claim or lawsuit would be considered a correction, and not tampering. Corrections such as these are acceptable if they are made appropriately. What could be an appropriate method of correction?
Healthcare institutions/organizations could establish a policy for appropriate medical record corrections.
An addendum could be made to the medical record, denoting the date, time and author of the correction and the reason for the correction (according to a Medscape article by Samaritan G.)
Ideally, striking through the erroneous entry with a single line would be the easiest way to show it is a wrong entry.
Attention could be drawn to the corrected entry, if appropriate.
Experts advice that the wrong entry should not be removed or deleted because healthcare team members may have relied on that entry. Therefore, removing such data would alter the integrity of the medical record.
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Such authorized corrections make the medical record accurate and complete and will not be considered as altering the medical record.
Unauthorized or intentional “alteration� is when a provider, after receiving a notice of lawsuit, reviews the medical record and clarifies certain points in an attempt to aid the defense of the claim. These alterations will be understood as an intentional misrepresentation of the facts and can severely impact the ability to defend a claim. Physicians, attorneys and other entities in the medical-legal community as well as medical review companies serving the medical-legal sector welcome the benefits EHRs promise. However, there are new areas of liability. This is why providers must ensure proper and timely documentation so that the integrity of the medical record is not questioned. Metadata is one of the most significant features of the electronic health record, with its capability of revealing the source, context, reliability, genuineness and distribution of electronic evidence. It also highlights human behavior and has a major role to play in incriminating or acquitting a provider facing a medical malpractice lawsuit.
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