Your EMR is watching you

A recent article on American Medical News titled “Medical charting errors can drive patient liability suits” led with a case involving a bad outcome after coronary artery bypass surgery. The plaintiff’s attorney alleged that the doctors did not review the patient’s lab results or x-rays because they did not specific say so in the medical record.

The article quoted a defense attorney who said, “By the time [the doctors] are deposed, it’s three years later and they say, ‘I’m sure I looked at that,’ but there’s no charting to back it up.”

Unless there is something very unusual about the electronic medical record (EMR) used by the doctors in that case, there should be a very easy way to determine if they viewed the results in question.

A feature of every EMR that I am aware of is that each time a chart is accessed, the EMR records who accessed the record, where they accessed the record from, what they looked at and for how long they stayed on a page down to the second. It is like an electronic fingerprint with time included.

When I was a surgical department chairman, I had many opportunities to see how this worked.

For example, I was asked to review a situation in which a resident failed to call for help with a patient who was crashing in the ICU. An arterial blood gas showing severe metabolic acidosis was not acted upon on a timely way. The resident said that the nurse did not report the critical blood gas result to him after the lab phoned it to her. This could not be verified, but the EMR showed that he had seen the result some 30 minutes before calling his senior resident.

Another case centered on an allegation by a gynecologist that a consultant surgeon failed to respond promptly to a call to assist with a bleeding patient in the operating room. The EMR revealed that four days after the case, the gynecologist had altered her operative dictation to make it appear that she had called for the consultation much earlier in the course of the surgery than what actually had occurred.

A surgical resident looked at a chart of a patient who did not have a surgical problem and was not on his service. She denied having accessed the record. When it was reviewed, the EMR showed that she had looked at 9 separate sections of the chart and had spent more than 10 minutes doing so.

As is true of many reports about malpractice trials, important details about the heart surgery patient’s case are lacking. But surely the defense attorneys must have known that the EMR could be searched to see if and when the doctors in question looked at certain portions of the chart.

If all medical, nursing and ancillary staff members are not aware of the tracking features of EMRs, they should be. This is the same type of tracking that catches unauthorized personnel who peek at the chart of a celebrity or other prominent patient in the hospital.

Note the example of the recent Boston Marathon bomber who was hospitalized. Staff who were not involved in treating him were repeatedly warned not access his EMR.

Consider yourselves informed. Big brother is watching.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • Ron Smith

    Even if you log that a chart was accessed, that means nothing. It tells you nothing about whether a chart was reviewed. We have always had logging like this in our custom solution.

    What I added several years ago was though the ‘signing’ of the paper documents that are scanned in. You actually have to push a ‘button’ to sign and date that you looked at reports. It doesn’t mark it if just happen to see a document.

    This has been a proactive solution to the convenience of EMRs. EMRs are inherently not good at documenting automatically that doctors or staff reviewed records.

    I also have a section where I can make notes that I can sign and date that are specific to the chart as a whole. It also requires a specific button push and there are fields to tell what I was thinking and what I was planning.

    Ron Smith, MD
    www (dot) ronsmithmd (dot) com

    • Skeptical Scalpel

      Ron, thanks for commenting. We had a similar record at one hospital. When you opened the screen to look at the lab results, you clicked to indicated that you reviewed them. This of course does not always mean they were really scrutinized because you could simply click “Reviewed” without really thinking about it.

  • Suzi Q 38

    I don’t think that physicians should have access to patients files without a good reason…usually to record a visit or procedure.
    I don’t think that the EMR per se is going to create problems for physicians. It will however, make it difficult to change what was previously recorded. This could be a good thing.

    • Skeptical Scalpel

      Suzi, I agree. It’s impossible to alter a chart because all entries are time stamped.

  • Skeptical Scalpel

    Great story and nurse comments. EMRs are clearly not the panacea that they were supposed to be.

    • ninguem

      Skeptical, do you think the hospital would listen if the DOCTORS complained?

      Does the press pick up the doctor complaints?

      • Skeptical Scalpel

        Probably not. No one cares what we think.

      • LeoHolmMD

        Why is this?

        • southerndoc1

          Because there’s not a single medical association that has the balls of the California Nurses Association: they all whored themselves out long ago.

  • guest

    i have a pt who works at IT for Sutter. There have been IT layoffs and dysfunction in the dept for a long time that have not gotten addressed. I think he has seen this coming for a long time.

  • Suzi Q 38

    Thanks for the links. I will read them when time permits.
    I like your posts because you try to give us more information. I appreciate it.

    • ninguem

      Thanks.

      Sutter is not the only big multi-hospital, multi-site medical organization that has had it’s EMR crash and burn.

      I’ve seen it myself, trying to communicate with Big Box Multisite HMO in my area, on a patient that ended up in my office.

      As in, can I treat, or do I have to send to your place (30 miles away)?

      Couldn’t do a thing, they could not even acknowledge that the patient sitting in my office, was one of their HMO members. The whole system was down.

      The purpose of these big EMR systems is money and control, and nothing more. The big box organizations want the EMR’s to maximize revenue, government wants the EMR’s to control spending and regulate. They both want the EMR’s for “data-mining”.

      I had a nice, simple EMR for my solo practice. I loved it, it was cheap, it worked nicely for a small operation.

      Government comes in with “meaningful use”, quickly called “meaningless use”, mandates useless bells and whistles, the price triples, it’s now buggy as hell.

      Oh, and notice, the articles go into great depths over what the NURSES have to say about it.

      When the doctors complain, we’re technophobic Luddites and are ignored with a sneer.

  • susan RN

    Most EHR’s have the ability for the physician to electronically sign off on results, just like signing a paper lab result and scanning it into the patient chart. If there is argument that the physician didn’t review even with a signature (although electronic) they could argue that physicians didn’t review paper results either.
    In regards to the Sutter list of RN issues, the majority are human/management based (training, orders incorrectly entered, RN fatigue) not EHR.

  • bill10526

    Another reason to ban malpractice suits. Replace them with adverse outcome insurance paid by patients in advance of procedures.

  • ardellaeagle

    I suppose we all forget that little bit. Computers/The internet never forgets. If you put it out there/did it, there is an electronic record of it. Ignorance is no longer an excuse when it can be shown that you were were informed. Transparency at work.