Is your EMR legal?

By Pamela Lewis Dolan, AMNews staff. Oct. 13, 2008 in American Medical News Questions are emerging as more physicians go electronic. Federal Rules of Civil Procedure, approved by the U.S. Supreme Court in December 2006, not only make any electronically stored data discoverable in a trial, but also open up physicians to several new liabilities inherent in the detail electronic data provides. For example, if a nurse records information under your login and password, and that information is incorrect, you could be the one held liable. Or the record's metadata -- the time stamp of who entered what when -- can dispute a doctor's version of events. While EMRs are touted as a way to make life easier for physicians, health IT and legal professionals say they can make life miserable for a doctor who buys the wrong system, or uses it in the wrong way. "Where these issues can raise their heads is somewhat unpredictable," said Reed Gelzer, MD, co-founder of Advocates for Documentation Integrity and Compliance, an advocacy and consulting group that educates physicians and health care entities on the legal EMR. Dr. Gelzer said electronic records can save you when the record-keeping combines with the metadata to provide an accurate picture. But, as some recent cases of snooping hospital employees have proven, EMRs can also detect when someone violates HIPAA. And, just because an EMR creates something that looks like a medical record doesn't mean that document fits the legal definition of a medical record.