The transition from patient paper chart is dramatic and daunting. Paper charts spanning a number of years are rarely organized to accommodate an EHR based chart. Expedient approaches to paper chart transitions without considering the continuity of care and preservation of paper records could expose the practice to a variety of problems and issues.
Paper Chart Disposition – The disposition and the access to the paper chart contents will be examined during the discovery process. Of particular importance will be continuing access to relevant historic information on patient care and treatment. In some cases, relevant information could include a variety of treatments over a span of years.
EXAMPLE:
A medical practice identified a list of paper chart contents that were scanned into the EHR. The contents for scanning were selected by medical record clerks based on the list which included tests with abnormal findings. Scanned items were not marked or otherwise identified and all scanned items were returned to the appropriate location in the patient chart.
Based on the “best practice” recommendation of a vendor, an HCO did not scan any paper chart information into the EHR. Patient paper charts were delivered on demand when providers determined that the chart was needed to treat the patient.
DISCOVERY ISSUES:
What was the clinical basis for the decision of the disposition of the paper chart contents in the move to the EHR?
What was the basis and procedure used for scanning any, selected, or all paper chart contents into the patient EHR record?
What was the quality assurance process to assure that the scanning process was completed and correct?
Did the claim incident involve relevant information that was in the paper chart but not available through the EHR when incident occurred?
What was the procedure used by the practice to make paper chart contents available to the physician after the patient has been initially documented in the EHR?
Were any notations or other information added to the paper chart after the EHR was in use that were not noted in the EHR?
Were paper chart contents referenced for patient care after the EHR was in use scanned into the EHR?
Were any paper chart contents relevant to the incident not available in the EHR even though these same items were relevant to the care provided to the patient after the EHR was operational?
Did the claim incident involve relevant information that was in the EHR from the paper chart, but was not practically accessible in the EHR?
RISK REDUCTION STRATEGIES:
The disposition of the paper chart should be based on a clinically focused analysis of the paper chart relevancy to patient service and care. The analysis should be documented and approved by management of the practice.
The transition of the paper chart to the EHR should be based on a written procedure.
Any paper chart transition process involving clinical decision making should be performed by appropriately qualified and trained healthcare professionals.
A quality assurance procedure should verify the transition of paper records to the EHR.
All physicians and staff should be trained on the paper chart strategy and transitional issues.
Patient Introduction to the EHR – When the first visit for a patient is documented in an EHR, certain information should be entered into the EHR to support patient care and establish treatment context. Indeed, many EHR systems depend on relevant patient information to trigger care standards. The discovery process will examine the manner in which a patient was initially introduced to the EHR and the basis for the entry of initial patient information.
EXAMPLE:
Annual checks for patients with hip replacements will not be detected by the EHR unless the hip replacement has been entered as a previous procedure.
Failure to enter information on care triggers will produce a variety of false notifications that will undermine EHR accuracy. Failing to record the last colonoscopy will trigger false notifications that the patient is due for the procedure. Similarly, failure to enter patient immunizations will produce incorrect warnings about appropriate patient care. Incorrect warnings could lead staff to ignore all warnings, or, more seriously, disable care warnings.
DISCOVERY ISSUES:
Was the claim incident related to any of the information that was entered from the paper chart into the patient EHR record?
Did any of the information initially entered for the patient differ from the clinical representations in the patient’s paper chart?
What were the qualifications of the parties who located or entered the information from the paper chart into the EHR?
What quality assurance measures were used to assure that paper chart information was properly interpreted and accurately entered into the EHR?
Did the timing of the entry of information into the EHR affect patient care related to the incident?
Did the entry of initial patient information result in disabling or altering any standard EHR features?
Did the failure to enter appropriate information from the paper chart into the EHR result in false messages about the patient treatment or care status related to the incident?
Did the failure to enter appropriate information from the paper chart into the EHR fail to trigger patient care messages that were appropriate for the patient and related to the incident?
RISK REDUCTION STRATEGIES:
Physicians should analyze the key information that is needed in the EHR to properly set up patients and trigger appropriate patient care activities. For example, key patient diagnoses should be entered to trigger patient care activities and drug allergy warnings.
The chief medical officer and practice management should validate the EHR patient information strategy.
A written procedure should be developed to frame the collection of relevant patient information and the entry of information into the EHR.
Qualified clinical personnel should be responsible for gathering information from the patient’s paper chart, and entering the selected information into the EHR.
A quality assurance procedure should be used to verify the information as well as compliance with the protocol.
CONCLUSION
EHRs can produce documentation to defend against a malpractice claim by providing a detailed record of patient care and physician due diligence. However, EHR implementation and use issues may also present patient records that can expose HCOs and practices to issues and questions which may undermine medical treatment and malpractice defense.
Effective transition from the paper chart must focus on preserving the integrity of the patient chart and assure continuity of care through the proper transition from the paper record and proper initial entry of patient information into the EHR.
Future parts of this White Paper Series will address other aspects of EHRs and medical malpractice discovery.
About the Series
(C) Sterling Solutions, Ltd., 2011
About the Series
(C) Sterling Solutions, Ltd., 2011
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