Volume 26

Number 2

Summer 2015

THE JOURNAL OF egal Nurse Consulting

ELECTRONIC MEDICAL RECORDS Organizes your existing facts so well, you’ll have time to find new ones.

LexisNexis® has two software applications designed around a legal nurse consultant’s workload: CaseMap® and MedMal Navigator®, our newest offering.

CaseMap® helps you better organize and analyze your data, including issues, documents, people, research, and more. It’s simple - whenever you come across an important fact, just right click to send it to CaseMap. (PDFs, Microsoft® Word, Outlook, lexis.com® and more are supported.) CaseMap has search, reporting and interface tools which help you tie together the Quickly link issues by checking a box. evidence, and see connections you might otherwise miss. Filters help you dig deep into your case.

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Solutions for Legal Nurse Consultants: CaseMap® and our newest offering, LexisNexis MedMal Navigator®

LexisNexis and the Knowledge Burst logo are registered trademarks of Reed Elsevier For more information, contact Jenee Schrule 904.315.4786 Inc., used under license. CaseMap is a registered trademark of LexisNexis, a division of Reed Elsevier Inc. © 2015 LexisNexis. All rights reserved. www.lexisnexis.com/casemap THE JOURNAL OF egal Nurse Consulting Volume 26 | Number 2 | Summer 2015

08 29 A REVIEW OF ELECTRONIC DOCUMENTED — BUT NOT DONE HEALTH RECORDS FOR LEGAL Katy Jones MSN, RN, LNC NURSE CONSULTANTS Now we're seeing plaintiffs file lawsuits claiming that documen- Bryan A. Wilbanks, DNP, CRNA tation was done, but the care wasn’t actually performed. Why? Information management systems are in widespread use in re- sponse to legislation promoting health information technology. 31 What does that mean for LNC practice? ROUNDTABLE DISCUSSION ON ELECTRONIC HEALTH RECORDS 14 Curated by Cheryl Gatti, BSN, RN, LNCC-R ELECTRONIC HEALTH RECORDS: We posted five questions focused on EHR on the AALNC web- THE PROMISE AND REALITY site asking members to identify problems they have encoun- Patricia Iyer, MSN, RN, LNCC; tered. Here's what they said. Armand Leone, MD, JD; and, Rebecca J. Zapatochny Rufo, DNSc, RN, CCRN The problems with paper medical records have been changed into new and different problems with EHRs. Many hidden fac- 02 Manuscript Review Process tors affect the safety and usability of EHRs. 03 Article Submission Guidelines 21 04 From the President AUDIT LOGS Scott Greene, CEO, Evidence Solutions, Inc. 05 From the Editor Data breaches, audit logs, security, how to ask for records, and how to recognize the ease by which records can be altered. 06 Letters to the Editor 25 FOLLOW THE AUDIT TRAIL Jennifer L. Keel, JD What can you learn from an audit trail to help your client? The possibilities abound.

VOLUME 26 | ISSUE 1 | SPRING 2015 | 1 | PURPOSE American Association of The purpose of The Journal is to promote legal nurse consulting within the medicallegal community; Legal Nurse Consultants to provide novice and experienced legal nurse consultants (LNCs) with a quality professional 330 North Wabash Ave. publication; and to teach and inform LNCs about clinical practice, current legal issues, and Suite 2000 professional development. Chicago, IL 60611 877/402-2562 312/321-5177 MANUSCRIPT SUBMISSION Fax: 312/673-6655 E-mail: [email protected] The Journal accepts original articles, case studies, letters, and research. Query letters are welcomed Web site: www.aalnc.org but not required. Material must be original and never published before. A manuscript should be submitted with the understanding that it is not being sent to any other journal simultaneously. BOARD OF DIRECTORS Manuscripts should be addressed to [email protected]. Please see the next page for Information for President Authors before submitting. Varsha Desai, BSN, RN, CNLCP, LNCC President-Elect MANUSCRIPT REVIEW PROCESS Susan Carleo, RN, CAPA, LNCC We send all submissions blinded to peer reviewers and return their blinded suggestions to the Past President author. The final version may have minor editing for form and authors will have final approval before Julie Dickinson, MBA, BSN, RN, LNCC publication. Acceptance is based on the quality of the material and its importance to the audience. Secretary/Treasurer Mary K. Sussex, MBA, MSN, RN-BC, The Journal of Legal Nurse Consulting is the official publication of the American Association of LNCC, CNLCP Legal Nurse Consultants (AALNC) and is a refereed journal. Journal articles express the authors’ Directors at Large views only and are not necessarily the official policy of AALNC or the editors of the journal. The Kim Beladi, BSN, RN, LNCC Debbie Pritts, RN, LNCC association reserves the right to accept, reject or alter all editorial and advertising material submitted Elizabeth Murray, BSN, RN, LNCC for publication.

THE JOURNAL OF LEGAL The content of this publication is for informational purposes only. Neither the Publisher nor NURSE CONSULTING AALNC assumes any responsibility for any injury and/or damage to persons or property arising out of any claim, including but not limited to product liability and/or negligence, arising out of Editor Wendie A. Howland, MN, RN-BC, the use, performance or operation of any methods, products, instructions, or ideas contained in CRRN, CCM, CNLCP, LNCP-C, LNCC the material herein. The reader shall assume all risks in connection with his/her use of any of the Editorial Committee For This Issue: information contained in this journal. Neither the Publisher nor AALNC shall be held responsible Kathleen Ashton PhD, RN, ACNS-BC for errors, omissions in medical information given nor liable for any special, consequential, Randall Clarke, BSN, RN or exemplary damages resulting, in whole or in part, from any reader’s use of or reliance on Tracy Coles BS, RN this material. Becky Czarnik MS, RN, CLNC, LNCP-C Pat Davis, MSN, RN The appearance of advertising in the The Journal of Legal Nurse Consulting does not constitute Cheryl Gatti BSN RN LNCC CCRN-R a guarantee or endorsement of the quality or value of such product or of the claims made for it Erin Gollogly BSN, RN by its manufacturer. The fact that a product, service, or company is advertised in The Journal of James Hanus, BSN, RN, OCN, MHA Legal Nurse Consulting shall not be referred to by the manufacturer in collateral advertising. For Elizabeth Hill, PhD, RN advertising information, contact [email protected] or call 877/402-2562. Patsy Langford, BSN, RN, MNA, CRNA Alister Morris MSN, RN, LNC Copyright ©2015 by the American Association of Legal Nurse Consultants. All rights reserved. Ann Peterson EdD, MSN, RN, For permission to reprint articles or charts from this journal, please send a written request noting FNP-BC, LNCC the title of the article, the year of publication, the volume number, and the page number to Steve Schweon MSN, RN, MPH, CIC, Permissions, Journal of Legal Nurse Consulting, 330 North Wabash Ave., Suite 2000, Chicago, IL HEM, FSHEA 60611; JLNC@ aalnc.org. Permission to reprint will not be unreasonably withheld. Susan Smith DNP, RN, CEN, CCRN Deborah S. (Susie) White BSN, RN Journal of Legal Nurse Consulting (ISSN 1080-3297) is published digitally by the American Association Elizabeth Zorn BSN, RN, LNCC of Legal Nurse Consultants, 330 North Wabash Ave., Suite 2000, Chicago, IL 60611, 877/402-2562. Members of the American Association of Legal Nurse Consultants receive a subscription to Journal STAFF of Legal Nurse Consulting as a benefit of membership. Subscriptions are available to non-members Executive Director for $165 per year. Back issues are avaiable for free download for members at the Association website Kristin Dee and $40 per copy for non-members subject to availability; prices are subject to change without notice. Back issues more than a year old can be obtained through the Cumulative Index to & Allied Health Literature (CINAHL). CINAHL’s customer service number is 818/409-8005. Address all subscriptions correspondence to Circulation Department, Journal of Legal Nurse Consulting, 330 North Wabash Ave., Suite 2000, Chicago, IL 60611. Include the old and new address on change requests and allow 6 weeks for the change.

| 2 | THE JOURNAL OF LEGAL NURSE CONSULTING ARTICLE SUBMISSION The Journal of Legal Nurse Consulting (JLNC), a refereed publication, is the official journal of the American Association of Legal Nurse Consultants (AALNC). We invite interested nurses and allied professionals to submit article queries or manuscripts that educate and inform our readership about current practice methods, professional development, and the promotion of legal nurse consulting within the medical-legal community. Manuscript submissions are peer-reviewed by professional LNCs with diverse professional backgrounds. The JLNC follows the ethical guidelines of COPE, the Committee on Publication Ethics, which may be reviewed at: http://publicationethics.org/resources/ code-conduct.

We particularly encourage first-time authors to submit manuscripts. The editor will provide writing and conceptual assistance as needed. Please follow this checklist for articles submitted for consideration.

INSTRUCTIONS FOR TEXT • Manuscript length: 1500 – 4000 words • Use Word© format only (.doc or .docx) • Submit only original manuscript not under consideration by other publications • Put title and page number in a header on each page (using the Header feature in Word) • Place author name, contact information, and article title on a separate title page, so author name can be blinded for peer review • Text: Use APA style (Publication Manual of the American Psychological Association, 6th edition) (https://owl.english.purdue.edu/owl/resource/560/01/) • Legal citations: Use The Bluebook: A Uniform System of Citation (15th ed.), Cambridge, MA: The Harvard Law Review Association • Live links are encouraged. Please include the full URL for each. Be careful that any automatic formatting does not break links and that they are all fully functional. • Note current retrieval date for all online references. • Include a 100-word abstract and keywords on the first page • Submit your article as an email attachment, with document title articlename.doc, e.g., wheelchairs.doc

INSTRUCTIONS FOR ART, FIGURES, TABLES, LINKS • All photos, figures, and artwork should be in JPG or PDF format (JPG preferred for photos). Line art should have a minimum resolution of 1000 dpi, halftone art (photos) a minimum of 300 dpi, and combination art (line/tone) a minimum of 500 dpi. • Each table, figure, photo, or art should be submitted as a separate file attachment, labeled to match its reference in text, with credits if needed (e.g., Table 1, Common nursing diagnoses in SCI; Figure 3, Time to endpoints by intervention, American Cancer Society, 2003)

INSTRUCTIONS FOR PERMISSIONS The author must accompany the submission with written release from: • Any recognizable identified facility or patient/client, for the use of their name or image • Any recognizable person in a photograph, for unrestricted use of the image • Any copyright holder, for copyrighted materials including illustrations, photographs, tables, etc. • All authors must disclose any relationship with facilities, institutions, organizations, or companies mentioned

GENERAL INFORMATION Acceptance will be based on the importance of the material for the audience and the quality of the material, and cannot be guaranteed. All accepted manuscripts are subject to editing, which may involve only minor changes of grammar, punctuation, paragraphing, etc. However, some editing may involve condensing or restructuring the narrative. Authors will be notified of extensive editing. Authors will approve the final revision for submission.

The author, not the Journal, is responsible for the views and conclusions of a published manuscript. The author will assign copyright to JLNC upon acceptance of the article. Permission for reprints or reproduction must be obtained from AALNC and will not be unreasonably withheld.

VOLUME 26 | ISSUE 2 | SUMMER 2015 | 3 | FROM THE PRESIDENT

A Message from the President

ALNC completed another successful educational and networking annual Forum from April 16-18 in Indianapolis, IN. During our annual Forum, we reviewed the State of the Associa- Ation and discussed the upcoming year of what you can expect from your Association. AALNC’s top three objectives from the strategic plan include: Varsha Desai 1. Position AALNC as the industry leader BSN, RN, CNLCP, LNCC 2. Increase the visibility of AALNC

President, AALNC 3. Develop a sound business model Based on AALNC’s strategic plan, here are some highlights for the 2015- 2016 year: 1. AALNC Education and Networking as the industry leader • LNC online course- Phase 2 will be rolling out later this year • At the Forum, the Products & Services Committee developed a 2-sided reference card for evi- dence-based research, available for purchase at the Forum. Due to the success of the reference card, we’ll develop more on additional topics. • Explore options for AALNC to offer mentoring programs for members. • Continue to develop the Forum into an educational and networking experience for new and long-time members. • Revise the AALNC Principles & Practice and explore opportunities to create an online version. 2. AALNC will be the voice for LNCs • Produce new and updated AALNC social media platforms • Roll out the revamped AALNC website in 2nd quarter 2016 • Develop partnerships in the legal and clinical community to exchange speakers, webinars, and journal articles to increase the Association’s visibility 3. Sound business model for AALNC • Revisit and update the strategic plan for 2015-2016 • Reinvest 2015 operating surplus into new and future AALNC projects • Continue exploring and adding member benefits. • Work on branding our message as the industry leader for education and networking to all LNCs. Make AALNC the place to be for education and networking. If you missed this year’s AALNC Forum, please mark your calendars for the AALNC Education and Networking Forum from April 21-23, 2016 in Charlotte, NC.

Varsha Desai BSN, RN, CNLCP, LNCC President, AALNC

| 4 | THE JOURNAL OF LEGAL NURSE CONSULTING

continued on page 6 FROM THE EDITOR

June 2015 Editor's Note

elcome to the June 2015 issue of the Journal of Legal Nurse Consulting. I hope you have all completely recovered from PSSD (post-snow stress disorder) and are free to W enjoy the return of Demeter for her six months of life aboveground. We’re focusing on electronic health records (EHR), and I must say, I’ve learned a lot of very interesting things while we’ve been putting it together. One thing that struck me was the stark contrast between the Wendie Howland early rosy predictions of integration, accessibility, and accuracy and the emerging reports of fragmen- MN, RN-BC, CRRN, tation, confusion, and self-propagating errors. We’ve been planning this issue for a year during which CNLCP, LNCC professional, popular, and social media offer accounts of serious problems more and more often. Editor, JLNC I don’t know the solution. Some writers I’ve seen are starting to recall the days of handwritten notes with a wistfulness that’s almost endearing. Yes, I do remember the days when a ward clerk would approach me with a hopeful, “Do you read Barnett?” as if Dr. Barnett’s handwriting were an exotic foreign script requiring special expertise to translate (it did). I also remember being able to flip through a chart and pull out notes from different services or providers by color-coded form, handwriting, or fountain pen ink with ease.

While putting this issue together, one thing that struck me was the stark contrast between the early rosy predictions of integration, accessibility, and accuracy and the emerging reports of fragmentation, confusion, and self-propagating errors.

Many LNCs who get big EHR files, in their varied forms, get cross-eyed looking at hundreds -or thousands- of nearly-identical pages. While Adobe and OCR (optical character recognition) are great helps, they can’t recognize errors hiding like needles in haystacks. And let’s not even start with the dictation bloopers. We’ll share some that will make you chuckle. If we can’t fix it, we might as well laugh. Apropos of finding useful things in big piles, I’d like to offer a special shout-out to Barb Boschert and her crew of volunteers who took up a monumental task: indexing every issue of the last ten years of JLNC. Barb received an award for outstanding service to the Association in Indianapolis, and we all owe her a debt of gratitude. Thank her when you see her!

Wendie A. Howland [email protected]

VOLUME 26 | ISSUE 2 | SUMMER 2015 | 5 | LETTERS TO THE EDITOR

online, as my lists are public and search EHR PROBLEMS: GET THE engine indexed. I will also list these jour- EAR OF ONC’S SENIOR nals in my Social Work and Public Health POLICY ANALYST Research Guides on the Temple University To the editor, research guide website as well as my own copies of these guides on Google Sites. Some weeks ago, I corresponded with an attorney and Senior Policy Advisor to the David Dillard, Temple University Office of the National Coordinator for Philadelphia, PA Health Information Technology (ONC). The ONC is that division of the Depart- FROM THE LNCEXCHANGE ment of Health and Human Services to ‘The president-elect of the American carry out the mandate to have all patients’ Medical Association says there is “a records on Electronic Health Records Sys- crying need” to make electronic health tems (EHRs) as soon as possible. record systems “time-saving rather than One of the topics of interest is the difficul- efficiency-diminishing.” ties attorneys are experiencing with EHRs systems are so in carrying out their duties as organiza- complicated and poorly designed that tions’ legal counsel, as plaintiff’s attorneys, FAN MAIL they are impacting the quality of doctors’ or as defense attorneys. The ONC has I love the design and “flavor” of the new clinical decisions and challenging the sus- observed that they are hearing of no such AALNC Journal! While much of the tainability of their practices.’ difficulties in, for example, health law and information in the old issues was good, it For the full article, click on: health law professionals meetings such as was embedded in more scholarly and stiff the American Health Lawyers Asso- language. The journal was less visually http://www.healthleadersmedia. ciation (AHLA). My own experience appealing, too. com/content/TEC-308463/EHR-Sys- is that increasing numbers of attorneys tems-Immature-Costly-AMA-Says are conveying to me that their tasks are Articles now are so interesting and func- Joanne Walker RN CNOR becoming much more difficult with EHRs tional in the sense that they are useful for Palmdale, CA for a variety of reasons. However, I have nurses in their daily practice. The design, no means to substantiate this. It is this colors and graphics draw the reader right latter point that I am seeking to test and in. Readers may consider branching out to facilitate informative communications within his or her own practice or even with policymakers. consider submitting an article! Please consider this request: Linda Husted, MPH, RN, CNLCP, LNCC, CCM, CDMS, CRC Write a letter addressed to ONC Senior East Setauket, New York Policy Advisor, either directly or, if you prefer, in care of me. If the latter, send me the PDF version and I will immediately INCREASED VISIBILITY pass it along. Arbitrarily I provide the FOR JLNC following recommendations and guidance: I am planning in the very near future to 1. O ne or two pages (again, in .pdf, so it post about the JLNC and JNLCP full text cannot be altered.) and then to my ten or so online lists and to 2. relevant library-related lists. Description of at least one specific example of an inconvenience, additional It is wonderful to have both of these cost, or other problematic change in your journals available at no cost to all readers work that has arisen because of the use and this will make them more prominent of EHR rather than a paper record.

| 6 | THE JOURNAL OF LEGAL NURSE CONSULTING 3. You are welcome to send your letter anonymously if you deem this nec- NEWS ITEM essary. However, it would be better Last November, the CFO of Shelby Regional Medical Center in Texas though if you identified yourself in pled guilty to falsely attesting to the meaningful use program on behalf the letter and, even better, offered the of the hospital during the 2012 reporting period. He also pled guilty to ONC an opportunity (and means) to aggravated identity theft for using a hospital worker’s name to falsely contact you directly to follow up. attest to meaningful use. The false attestations resulted in Shelby and other hospitals owned by Tariq Mahmood to receive close to $17 million If you have any questions or prefer to discuss in incentive payments from CMS. Mahmood was sentenced to 11 years a different means by phone, you are welcome in prison for the fraud last month. The CFO has agreed to to contact me.Thank you for your interest in pay $4.4 million in restitution for his part in the fraudulent scheme. He the subject matter and for your help. will be sentenced later this month and could get up to seven years in federal prison. Sincerely, Linn Foster Friedman Reed D. Gelzer, MD, MPH, Posted In Health Information Privacy Co-Chair, HL7 EHR Standards http://www.dataprivacyandsecurityinsider.com/2015/05/hospital-cfo- Workgroup, Co-Facilitator, HL7 must-pay-4-4-million-for-falsely-attesting-to-meaningful-use/ Records Management and Evidentiary Support Workgroup Newbury, NH; Philadelphia, PA [email protected]

ERRATUM The last issue’s Presidential Pearl cred- ACTUAL ited to Elizabeth Zorn listed her as past president of the AALNCP. She is, of DICTATION course, past president of the AALNC. BLOOPERS FROM REAL CASES

FROM A 2014 MEDLINE ONLINE DISCUSSION ON EHR: • Review of systems green is completely unremarkable I have signed it Recommendations for doctors and it just bothers electronic with the exception of as who use EHRs: 1. Face me, noted in history of present illness not the computer. 2. Do not yada me sites … fasciotomy site swear at the computer and • tell me how bad it is. I do not • He also acknowledges that he is at dinner person is Alyce been there care about your woes with to help others as a hard time accepting help himself he is frustrated computers. You should have that he is not able to help others away he has in the past. paid better attention during 3. training sessions. Do not • Scene 4 basic narrower Val … Seen for basic neuro eval use a scribe. A new person in the room will ruin our commu- • Ruled out for Pullman area blind … Ruled out for pulmonary emboli nication. 4. Share the online record with me as we progress • Fiber-optic larynx Oscar be for this idea, fair and goalless offer through the exam. I can read, geo-phase … Fiberoptic laryngoscopy, pharyngoesophageal phase even scientific terminology.” — Patient comment • Get a soffit Graham … Get an esophagram

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 7 | FEATURE

A Review of Electronic Health Records for Legal Nurse Consultants Bryan A. Wilbanks, DNP, CRNA

Keywords: information management system, electronic medical record, electronic health record, electronic documentation

Use information management systems (IMS) is rapidly growing as hospitals transition to the electronic documentation. Information management systems have just recently been put into widespread clinical use in response to legislation promoting the use of health information technology. The purpose of this paper is to review the history and use of electronic health records with a focus on its significance to the practice of legal nurse consultants.

nformation management systems pressure, oxyhemoglobin saturation, etc.) The American Recovery and Reinvest- (IMSs) are used to acquire, process, allows the clinician to focus more on ment Act (ARRA) of 2009 promoted Iand record health care data specific deliveering patient care and less on gener- the meaningful use of health informa- to the medical or nursing care given at ating documentation. IMSs can improve tion technology and set the groundwork a specific location. Any IMS must be the patient record accuracy, completeness, for widespread conversion to electronic customized to the characteristics of and legibility if they are appropriately health records (EHR) (J. Stonemetz, its end users and work environment configured and implemented into clinical 2011). These provisions were outlined (Wilbanks, 2013). Consequently, each settings. While historically IMSs have in the Health Information Technology IMS implementation is unique. Auto- not enjoyed widespread acceptance, for Economic and Clinical Health Act matic acquisition and recording patients’ recent legislation are making them ubiq- (HITECH) and included financial physiological data (e.g., heart rate, blood uitous in modern healthcare. incentives (Blumenthal & Tavenner,

| 8 | THE JOURNAL OF LEGAL NURSE CONSULTING 2010). “Meaningful use” is defined by a Detmer, & Simborg, 2005). One of the to the main database server for data delineated set of objectives to be met in first EHR systems to be used in clinical storage and retrieval. This network order for the facility to receive financial practice was COSTAR (Comprehen- allows automated data sharing between reimbursement or other incentive. Some sive Medical Information System for different hospital departments. Data include maintaining up-to-date patient Ambulatory Care) and was initially collected in one department can auto- health histories, vital signs, medica- implemented into a single primary matically populate corresponding data tion lists, allergy lists, and summaries medical care practice located in Boston, fields in the EHR of other departments of delivered patient care. Clinical use Massachusetts, in 1969 (Barnett et al., (i.e., patient allergies or the name of of decision support tools to promote 1982). In 1978, COSTAR was made surgical procedure do not need to be patient safety and quality of care is a publically available for implementation re-entered in the intraoperative anes- major objective of the HITECH Act. at other primary medical practice clinics. thesia record if they were entered in the The purpose of this paper is to review preoperative department). the history and use of electronic health In 2009, when approximately 10% of Exact features, functionality, and records with implications for legal nurse all hospitals used EHRs, the ARRA of connectivity to other EHRs depend consultants. A review of important 2009 designated $19 billion to promote on the particular IMS vendor; there concepts specific to electronic documen- adopting health information technol- are no universally accepted guidelines tation is included. ogy into clinical practice (Blumenthal, 2009). ARRA provided that Medicare for this. An IMS may be restricted to a would give financial incentives to orga- given area of patient care, or it could be A BRIEF HISTORY nizations demonstrating “meaningful” fully integrated into a hospital’s EHR OF THE ELECTRONIC use of an EHR system by 2011, with database, allowing it to communicate HEALTH RECORD the incentives potentially maxing out with other hospital departments, such The term “electronic health record” does at $44,000 in 2016 when the incen- as laboratory services or nursing units. not currently have a single universal tives expired. Additionally, Medicare IMSs were intended to be beneficial in definition. It is used in many diverse implemented a schedule of reduced generating patient care records, clinical settings and has many different types of reimbursement rates for physicians that decision support, quality assurance, associated data (Hayrinen, Saranto, & failed to “meaningfully” utilize EHRs by quality improvement, research purpos- Nykanen, 2008). The basic definition 2015, with the penalty increasing 1% es, automated charge capturing, and as defined by the International Orga- annually over a three-year period. patient tracking (Shah, Tremper, & nization for Standardization (ISO) is, Kheterpal, 2011). These changes were meant to improve “a repository of patient data in digital the quality of health care, improve Some of the earliest IMSs in clinical form, stored and exchanged securely, patient safety, and help to control use were generic data-capturing systems and accessible by multiple authorized health care costs. However, information created by providers. Their users” (2004). An EHR is used to define technology in clinical settings has been main purpose was to automatically patient care objectives, document patient associated with unintended consequenc- capture and document physiological care delivery, and promote assessment of es, defined as adverse events that are a parameters from vital sign monitors and patient responses. The EHR is a power- direct result of the implementation or anesthesia machines (Muravchick et ful tool for clinical decision support. The use of information technology in clinical al., 2008). These were used at a spe- environment the EHR is implemented settings (Meeks et al., 2014). cific location (i.e., not widely used or determines the precise form the EHR available commercially), and a system’s takes. Taking the same IMS and imple- capabilities were limited by its design- IMS IN PRACTICE menting it into two different settings can er’s computer science knowledge and result in completely different systems A modern IMS (Jerry Stonemetz & ability. Today, extensive customization because of the different human-com- Ruskin, 2008) includes proprietary is needed to realize many of the benefits puter interactions; system users and software, computer hardware, and of an IMS. patients alter the way the system is used possibly a physiological device interface in real-world settings. through which the documentation The major benefits of these systems are system communicates with patient related to the ability to search and query The first use of electronic computers in monitoring equipment. the databases they create. Effective a health care setting involved roles in clinical decision support tools (Chau clinical decision support, management, The IMS uses a local area network (or & Ehrenfeld, 2011) can monitor the and financial applications (Berner, possibly a wireless network) to connect collected patient data in real time to

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 9 | of Healthcare Organizations (JCA- Information technology in clinical settings HO). Compliance with preoperative has been associated with unintended antibiotic administration (B. G. Nair, Newman, Peterson, & Schwid, 2011; consequences, adverse events that are O'Reilly, Talsma, VanRiper, Kheterpal, & Burney, 2006; Wax et al., 2007) and a direct result of implementing or using appropriate beta-blocker administration information technology. during surgical procedures (B. Nair, Newman, Peterson, & Schwid, 2012; B. G. Nair et al., 2012) improved at many facilities through automated reminders to anesthesia providers. Compliance provide immediate feedback to the charting of patients’ physiological param- with many national standards or goals health care provider according to pre- eters from vital sign monitoring devices could be easily assessed and document- defined sets of rules (e.g., reminder to may be more representative of actual ed with an electronic reservoir of data. re-dose antibiotics during long surgical values. Underreporting of adverse events procedures, or alert the provider to a has been reported in several studies IMS AND RESEARCH failure to record patient vital signs for a (Benson et al., 2000; Sanborn, Castro, As the use of IMSs increase so will the predetermined period of time). Kuroda, & Thys, 1996; Simpao, Pruitt, Cook-Sather, Gurnaney, & Rehman, amount of data available for research. A Many studies suggested that electronic 2012), and automated collection of phys- study by Junger et al. (2001), one of the documentation produces more accurate iological patient data may make detecting first to use an IMS database for clinical and complete documentation than paper adverse events easier. research, sought to identify risk factors (Cook, McDonald, & Nunziata, 1989; for postoperative nausea and vomiting, widely documented in the published Lerou, Dirksen, van Daele, Nijhuis, & DECISION SUPPORT TOOLS Crul, 1988; Reich et al., 2000). Wright- literature. It demonstrated that an son (2010) performed a chart review An IMS can include real-time clinical IMS database could be used for clinical that showed no statistically significant decision support tools to insure compli- research, reaching the same conclusions difference in information completeness ance with national patient care standards as more traditional clinical research between electronic and manual records, and quality improvement/assurance methods. In 2008, Vigoda et al. studied though incompleteness varied between initiatives (Chau & Ehrenfeld, 2011). identifying gender disparities in the the two. Electronic records were more Clinical decision support tools can be treatment of coronary artery disease, and complete in respect to the drugs admin- used to improve patient outcomes by demonstrated that the databases gener- istered and data elements that could be preventing errors, supporting a quick- ated by multiple IMS could be pooled automatically imported from electronic er response to adverse events, and by and used for epidemiological research. devices (e.g., physiological monitoring providing a dependable mechanism to track adverse events (Bates & Gawande, devices or gas analyzers). Handwritten IMS AND 2003). Automated chart reviews, before patient records in Wrightson’s study were FINANCIAL EFFECT confirming the information in the chart more complete in patient weight, name and making it a permanent legal record Facilities can automate billing for of surgeons performing the procedure, of care, can be used to detect empty services and supplies using an IMS, patient physical status score, and descrip- fields. This requires the clinician to enter insuring that many potential charges are tions of equipment used in patient care. missing mandatory information in order automatically captured. Many IMS have Thrush (1992) suggested that observer to finalize the chart. These types of a point-of-care charge-capturing system bias, missed vital sign readings, and decision support tools could potentially in the user interface. Automated charge memory recall inaccuracies could be decrease legal liability and malpractice rules can be built in to automatically avoided with automated charting sys- claims (Chau & Ehrenfeld, 2011). charge for certain supplies in response tems; furthermore, Thrush’s study noted to the documentation of certain events that clinicians were less likely to record Many types of clinical decision support (e.g., automatically entering professional extreme physiological values and to tools are in use in clinical practice, with fees for arterial line insertion and sup- “smooth” the recorded vital signs to create many focusing on achieving the national plies used when the clinician documents the “railroad” vital sign tracks that reflect patient safety goals as set forth by the arterial line placement). The databases a more stable clinical picture. Automated Joint Commission on the Accreditation created by an IMS can be used to help

| 10 | THE JOURNAL OF LEGAL NURSE CONSULTING guide staffing decisions for the entire to read. Readability (Wilbanks, 2014 altered. Proving whether documenta- operating room, which could save mon- #342) is defined as how well the final tion was altered because of artifacts or ey by allowing appropriate utilization of electronic healthcare record provides an as a willful attempt to conceal abnormal human resources (Junger et al., 2002). understandable report of care. The con- values can be very difficult, and will Reich et al. (2006) demonstrated that cept of EHR readability is similar to the most likely require evaluation by an an IMS reduces the time it takes to bill concept of legibility of manual paper- . for anesthesia services and improves based records. While EHR may provide compliance with billing requirements a more accurate and complete narrative, DATA ENTRY while reducing personnel time. it can be much more difficult to read. EHR documentation is usually gener- is defined as “data about data” ated using computer-assisted data entry IMPLICATIONS OF IMS Metadata (McLean, Burton, Haller, & McLean, methods that must be custom-built to FOR LEGAL NURSE 2008). The IMS creates it whenever the specific requirements of the end-us- CONSULTANTS data is entered or altered. Metadata ers (Duftschmid & Wrba, 2004). Data Many implications of IMS of interest can be used to track data entry times can be entered using standard electronic to legal nurse consultants are related or documentation changes. Remember data selection methods (Chen, Enberg, to three primary functions addressed that physiological monitoring data is & Klein, 2007)(e.g., item selection below. These are primarily related to entered automatically so is much more through radio-buttons or drop-down the effect of documentation quality as it likely to be accurate. If severely abnor- menus) or using complete blocks of applies to malpractice liability, confiden- mal vital signs are altered in the IMS standardized text that must be manually tiality laws, data ownership disputes, and database, e.g., to make a patient condi- edited using a keyboard if actual patient identification of insurance fraud (Man- tion appear more stable, then metadata care is different from the pre-defined galmurti, Murtagh, & Mello, 2010). could prove this. text (Wilbanks, Moss, & Berner, 2013). Metadata can also be used to verify Using standardized templates that must DATA COLLECTION documentation truthfulness, if, for be changed manually can result in inac- The use of IMS can greatly increase the example, an anesthesiologist falsifies curate documentation if the clinician amount of information collected for doc- documentation by entering that the does not use them as intended. In one umentation into the EHR (Wilbanks, patient arrived in the recovery room operating room study (Wilbanks et al., 2014). This can help prove or disprove with no complications, and the metada- 2013), clinicians documented that they malpractice liability (Bowman, 2013) by ta clearly shows that the post-operative performed neuromuscular function test- providing a more complete and accurate note was actually entered almost seven ing before endotracheal extubation in all picture of events. This might include hours before arrival to the recovery room of the general anesthetic cases observed identifying contradicting documentation (Vigoda & Lubarsky, 2006). Metada- in the study, even though 20% of those (e.g., two different healthcare providers ta might be able to show if vital signs patients were never actually monitored who document very different informa- were automatically collected, manually for neuromuscular function using a tion about the same event). The legal entered, or altered. In addition, the nerve stimulator. This shows how inac- nurse consultant should keep in mind altered documentation can be compared curate documentation can result from that the gold standard for electronic to the original data to show the differ- using pre-defined templates if defaults documentation accuracy is that it is ence between the values. Metadata is are not changed to reflect actual events. written contemporaneously as direct not part of the usually-viewed clinical If legal nurse consultants evaluate how observations of what the documentation record per se, but it is stored in the IMS data are actually entered into the med- describes, or by direct corroboration database (McLean et al., 2008). Late ical record, then they might be able to with the individual who generated the electronic documentation that was identify inaccurate documentation that notes (Wilbanks, 2014). Therefore, the entered to appear as if it were charted results from the use of standardized legal nurse consultant needs the clini- earlier is easy to identify using metadata data entry templates. cian who generated the documentation (McLean et al., 2008). to validate the documentation, or find Copy-and-paste (Dimick, 2008; Gelzer witnesses who were present at the event Artifacts are erroneous data that were et al., 2009; Hirschtick, 2006; Markel, who can testify about it. automatically collected and entered 2010; Siegler & Adelman, 2009) can into the EHR (Wilbanks, 2014). cause errors when a clinician enters Electronic documentation can be These must be distinguished from real patient chart data into the computer difficult to evaluate because it’s difficult abnormal readings that were deceptively operating system into a different patient’s

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 11 | medical record to save time writing it de and widespread use in clinical practice. the United States. Journal of the American Medi- novo. Copy-and-paste functionality may The 2010 HITECH Act, government cal Informatics Association, 12(1). decrease end-user workload and total support of the use of health care tech- Blumenthal, D. (2009). Stimulating the adoption documentation time, but can result in nology in clinical practice, and CMS of health information technology. New England decreased documentation quality that requirements have each contributed to Journal of Medicine, 360(15), 1477-1479. doi: 10.1056/NEJMp0901592 directly endangers patient safety and increased IMS use. IMS can improve can increase legal liability by promoting the quality of patient care and docu- Blumenthal, D., & Tavenner, M. (2010). The medical errors and fraudulent billing mentation records, and they have also "meaningful use" regulation for electronic health records. (Dimick, 2008). Copy-and-paste is very resulted in unintended consequences. New England Journal of Medicine, 363(6), 501-504. doi: 10.1056/NEJMp1006114 similar to using pre-defined templates; IMS can: however, copy-and-paste is re-use of Bowman, S. (2013). Impact of electronic health • Play an important role in quality record systems on information integrity: quality notes from a specific patient to a different improvement and assurance initiatives and safety implications. Perspect Health Inf patient (Gelzer et al., 2009), as compared Manag, 10, 1c. to not updating pre-defined default • Improve the accuracy and complete- ness of the generated EHR Chau, A., & Ehrenfeld, J. M. (2011). Using generic statements used for all patients. real-time clinical decision support to improve • Improve financial reimbursements performance on perioperative quality and process CLINICAL DECISION- through a more accurate and efficient measures. Anesthesiol Clin, 29(1), 57-69. doi: MAKING billing system 10.1016/j.anclin.2010.11.002 Clinical decision support tools can • Serve as a database for clinical research Chen, R., Enberg, G., & Klein, G. O. (2007). • Facilitate adherence to documenta- Julius--a template based supplementary electron- result in errors from serious design ic health record system. BMC Med Inform Decis flaws, selecting and applying improper tion standards of practice Mak, 7, 10. doi: 10.1186/1472-6947-7-10 decision support rules, human errors, The legal nurse consultant must be Cook, R. I., McDonald, J. S., & Nunziata, E. poor end-user training, alert fatigue, or able to analyze the large volumes of (1989). Differences between handwritten and improper use (Bowman, 2013). Two information available in the EHR and automatic blood pressure records. Anesthesiology, concepts are important here. understand the effect that using elec- 71(3), 385-390. tronic data collection, data entry, and occurs when the system Dimick, C. (2008). Documentation bad habits. Alert fatigue clinical decision support tools can have Shortcuts in electronic records pose risk. J ahima, user stops responding to decision sup- on patient care. 79(6), 40-43; quiz 45-46. port alerts after excessive false alarms Duftschmid, G., & Wrba, T. (2004). A tool for (Ash, Sittig, Campbell, Guappone, REFERENCES the design of clinical forms supporting end-user & Dykstra, 2007). This could mean integration. Medical Informatics & the Internet in Ash, J. S., Sittig, D. F., Campbell, E. M., Guap- the clinician ignores warnings of an Medicine, 29(1), 29-41. pone, K. P., & Dykstra, R. H. (2007). Some impending adverse event (Bowman, unintended consequences of clinical decision Ehrenfeld, J. M., & Rehman, M. A. (2011). 2013), such as giving a drug to a patient support systems. AMIA Annu Symp Proc, 26-30. Anesthesia information management systems: a with an allergy to it or not recognizing a review of functionality and installation con- Barnett, G. O., Zielstorff, R. D., Piggins, J., siderations. Journal of Clinical Monitoring and cardiac dysrhythmia. McLatchey, J., Morgan, M. M., Barrett, S. M., . . . Computing, 25(1), 71-79. Epub 2010 Aug 2024. McDonnell, G. (1982). Costar: A comprehensive Automation bias occurs when a clinical medical information system for ambulatory care. Gelzer, R., Hall, T., Liette, E., Reeves, M. G., decision support tool suggests some- Proceedings of Annual Symposium on Computer Sundby, J., Tegen, A., . . . McCormick, K. (2009). thing inappropriate, and the clinician Application in Medical Care, 2, 8-18. Auditing copy and paste. J ahima, 80(1), 26-29; quiz 31-22. follows the advice (Bowman, 2013). It Bates, D. W., & Gawande, A. A. (2003). Improving is important to remember that deci- safety with information technology. New England Hayrinen, K., Saranto, K., & Nykanen, P. sion support tools are not completely Journal of Medicine, 348(25), 2526-2534. (2008). Definition, structure, content, use and impacts of electronic health records: a review reliable, and the clinician is ultimately Benson, M., Junger, A., Fuchs, C., Quinzio, L., of the research literature. International Journal responsible for patient care. Bottger, S., Jost, A., . . . Hempelmann, G. (2000). of Medical Informatics, 77(5), 291-304. doi: Using an anesthesia information management 10.1016/j.ijmedinf.2007.09.001 SUMMARY system to prove a deficit in voluntary reporting of adverse events in a quality assurance program. J Hirschtick, R. E. (2006). A piece of my mind. Although the introduction of electronic Clin Monit Comput., 16(3), 211-217. Copy-and-paste. Jama, 295(20), 2335-2336. doi: 10.1001/jama.295.20.2335 health records and information manage- Berner, E. S., Detmer, D. E., & Simborg, D. ment systems occurred decades ago they (2005). Will the wave finally break? A brief view ISO/DTR. (2004). - Electron- have been very slow to gain acceptance of the adoption of electronic medical records in ic Health Record - definition, scope, and context.

| 12 | THE JOURNAL OF LEGAL NURSE CONSULTING Junger, A., Benson, M., Quinzio, L., Michel, A., Improving documentation of a beta-blocker qual- have increased medical liability. Anesthesia and Sciuk, G., Brammen, D., . . . Hempelmann, G. ity measure through an anesthesia information Analgesia, 102(6), 1798-1802. doi: 10.1213/01. (2002). An Anesthesia Information Management management system and real-time notification of ane.0000217235.25350.5e System (AIMS) as a tool for controlling resource documentation errors. Joint Commission journal Vigoda, M. M., Rodriguez, L. I., Wu, E., Perry, management of operating rooms. Methods of on quality and patient safety / Joint Commission K., Duncan, R., Birnbach, D. J., & Lubarsky, D. Information in Medicine, 41(1), 81-85. Resources, 38(6), 283-288. A. (2008). The use of an anesthesia information Junger, A., Hartmann, B., Benson, M., Schindler, O'Reilly, M., Talsma, A., VanRiper, S., system to identify and trend gender disparities E., Dietrich, G., Jost, A., . . . Hempelmannn, G. Kheterpal, S., & Burney, R. (2006). An anes- in outpatient medical management of patients (2001). The use of an anesthesia information thesia information system designed to provide with coronary artery disease. Anesthesia and management system for prediction of antiemetic physician-specific feedback improves timely Analgesia, 107(1), 185-192. doi: 10.1213/01. rescue treatment at the postanesthesia care unit. administration of prophylactic antibiotics. Anes- ane.0000289651.65047.3b Anesthesia and Analgesia, 92(5), 1203-1209. (4), 908-912. thesia and Analgesia, 103 Wax, D. B., Beilin, Y., Levin, M., Chadha, N., Lerou, J. G., Dirksen, R., van Daele, M., Nijhuis, Reich, D. L., Kahn, R. A., Wax, D., Palvia, T., Krol, M., & Reich, D. L. (2007). The effect of G. M., & Crul, J. F. (1988). Automated charting Galati, M., & Krol, M. (2006). Development of an interactive visual reminder in an anesthesia of physiological variables in anesthesia: a a module for point-of-care charge capture and information management system on timeli- quantitative comparison of automated versus submission using an anesthesia information ness of prophylactic antibiotic administration. handwritten anesthesia records. Journal of Clini- management system. Anesthesiology, 105(1), 179- Anesthesia and Analgesia, 104(6), 1462. doi: cal Monitoring and Computing, 4(1), 37-47. 186; quiz 231-172. 10.1213/01.ane.0000263043.56372.5f Mangalmurti, S. S., Murtagh, L., & Mello, M. M. Reich, D. L., Wood, R. K., Jr., Mattar, R., Krol, Wilbanks, B. A. (2013). An integrative (2010). Medical malpractice liability in the age of M., Adams, D. C., Hossain, S., & Bodian, C. literature review of contextual factors in periop- electronic health records. N Engl J Med, 363(21), A. (2000). Arterial blood pressure and heart erative information mangagement systems. 2060-2067. doi: 10.1056/NEJMhle1005210 rate discrepancies between handwritten and CIN: Computers, Informatics, Nursing, 31(12), 622-628. Markel, A. (2010). Copy and paste of elec- computerized anesthesia records. Anesthesia and tronic health records: a modern medical Analgesia, 91(3), 612-616. Wilbanks, B. A. (2014). An integrative literature illness. Am J Med, 123(5), e9. doi: 10.1016/j. Sanborn, K. V., Castro, J., Kuroda, M., & Thys, review on accuracy in anesthesia information amjmed.2009.10.012 D. M. (1996). Detection of intraoperative management systems. CIN: Computers, Informat- ics, Nursing, 32(3), 56-63. McLean, T. R., Burton, L., Haller, C. C., & incidents by electronic scanning of computerized McLean, P. B. (2008). Electronic medical anesthesia records. Comparison with voluntary Wilbanks, B. A., Moss, J. A., & Berner, E. S. record metadata: uses and liability. J Am Coll reporting. Anesthesiology, 85(5), 977-987. (2013). An observational study of the accuracy Surg, 206(3), 405-411. doi: 10.1016/j.jamcoll- Shah, N. J., Tremper, K. K., & Kheterpal, S. and completeness of an anesthesia informa- surg.2007.09.018 (2011). Anatomy of an anesthesia information tion management system: recommendations for documentation system changes. Comput Meeks, D. W., Takian, A., Sittig, D. F., Singh, H., management system. Anesthesiol Clin, 29(3), Inform Nurs, 31(8), 359-367. doi: 10.1097/ & Barber, N. (2014). Exploring the sociotechni- 355-365. doi: 10.1016/j.anclin.2011.05.013 NXN.0b013e31829a8f4b cal intersection of patient safety and electronic Siegler, E. L., & Adelman, R. (2009). Copy health record implementation. Journal of the and paste: a remediable hazard of electronic Wrightson, W. A. (2010). A comparison of elec- American Medical Informatics Association, 21(e1), health records. Am J Med, 122(6), 495-496. doi: tronic and handwritten anaesthetic records for e28-e34. 10.1016/j.amjmed.2009.02.010 completeness of information. Anaesth Intensive Care., 38(6), 1052-1058. 4 Muravchick, S., Caldwell, J. E., Epstein, R. H., Simpao, A. F., Pruitt, E. Y., Cook-Sather, S. D., Galati, M., Levy, W. J., O'Reilly, M., . . . Vigoda, Gurnaney, H. G., & Rehman, M. A. (2012). The M. M. (2008). Anesthesia information manage- reliability of manual reporting of clinical events ment system implementation: a practical guide. in an anesthesia information management system Bryan A. Wilbanks has (5), 1598-1608. Anesthesia and Analgesia, 107 (AIMS). Journal of Clinical Monitoring and Com- twelve years of experience doi: 10.1213/ane.0b013e318187bc8f puting. doi: 10.1007/s10877-012-9371-z as a staff Nair, B., Newman, S., Peterson, G., & Schwid, Stonemetz, J. (2011). Anesthesia information at a large trauma center in H. (2012). Smart Anesthesia Manager (SAM) management systems marketplace and current Huntsville, Alabama. He is - A Real-time Decision Support System for vendors. Anesthesiol Clin, 29(3), 367-375. doi: also an informatics special- Anesthesia Care during Surgery. IEEE transac- 10.1016/j.anclin.2011.05.009 ist with a research focus on usability tions on bio-medical engineering. testing of information management Stonemetz, J., & Ruskin, K. (2008). Anesthesia Nair, B. G., Newman, S. F., Peterson, G. N., & systems. He is a candidate for the PhD informatics. London: Springer. Schwid, H. A. (2011). Automated electronic degree at the University of Alabama at reminders to improve redosing of antibiot- Thrush, D. N. (1992). Are automated anesthesia Birmingham in the school of nursing. ics during surgical cases: comparison of two records better? Journal of Clinical Anesthesia, Bryan also does volunteer work for the approaches. Surg Infect (Larchmt). 12(1), 57-63. 4(5), 386-389. American Association of Nurse Anesthe- Epub 2010 Dec 2020. Vigoda, M. M., & Lubarsky, D. A. (2006). tist where he helps review medical Nair, B. G., Peterson, G. N., Newman, S. F., Wu, Failure to recognize loss of incoming data malpractice closed claims. He can be W. Y., Kolios-Morris, V., & Schwid, H. A. (2012). in an anesthesia record-keeping system may contacted at [email protected].

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 13 | FEATURE

Electronic Health Records: The Promise and Reality Patricia Iyer, MSN, RN, LNCC; Armand Leone, MD, JD; and, Rebecca J. Zapatochny Rufo, DNSc, RN, CCRN

Keywords: electronic medical record, electronic health record, computerized medical records

EHRs held out the promise of faster, better and more coordinated healthcare and, on this promise, became a regulatory requirement for healthcare providers. Unfortunately, theory and practice are not the same. The problems with paper medical records have been changed into new and different problems with EHRs. Many hidden factors affect the safety and usability of EHRs. This article provides an overview of these factors.

nformation about an individual’s ed healthcare information to assist and data electronically. The Electronic most intimate details concerning her in treating a current patient required Healthcare Record (EHR) was a logical Ihealth, diseases, treatments, address, physically retrieving the chart from extension of the digitalization of data employer information and financial medical records department and sending and the promise that it held. information used to be written down by it to the nursing unit for the physician hand in the patient’s chart and physically to review. Release of healthcare informa- THE EHR REGULATORY stored securely in the medical records tion to other providers used to require DREAM room. Lab test results were printed the medical records department to locate In 2009, the American Reinvestment & out on the test result form and pasted and duplicate the chart. Then came the Recovery (ARRA) Act changed the way into the record. Use of prior record- computer and the ability to store records in which American medical clinicians

| 14 | THE JOURNAL OF LEGAL NURSE CONSULTING documented patient care. The Health incentive payments range from $44,000 EHRs took away from face-to-face time Information Technology for Economic over 5 years for the Medicare providers with patients and, even more concern- and Clinical Health (HITECH) Act and $63,750 over 6 years for Medicaid ing, 26% said that the new technology required that healthcare providers imple- providers (starting in 2011). Partic- decreased their ability to manage their ment Electronic Heath Records (EHR), ipation in the CMS EHR incentive patients’ care plans. Two thirds of phy- that physicians demonstrate meaningful program is totally voluntary, however sicians reported that note-writing took use and that those providers who do not if participating providers fail to join in more time. One third stated that it took implement an EHR system pay financial by 2015, there will be negative adjust- longer to find and review medical record penalties starting in 2015. (CDC 2012) ments to their Medicare/Medicaid fees data with the EHR than without, and a starting at 1% reduction and escalating similar percentage reported that it took MEANINGFUL USE to 3% reduction by 2017 and beyond. more time to read other clinicians’ notes. (CMS 2014) In 2015, an estimated “Meaningful use” was a mandate from 250,000 will face the 1% reduction in Although the EHR is an enormous the Office of the National Coordinator CMS payments due to meaningful use data resource, clinicians are having of Health Information Technology non-compliance. (Bell J. 2014) difficulty inputting clinical information or the ONC. (CDC 2014) The goal and, once the information is in, they are of “meaningful use” was to ensure the The belief that technology would elim- having finding the facts they are most use of interoperable electronic records inate errors and delays in patient care interested in. EHRs provide additional throughout the US healthcare delivery was so intoxicating that, even though complexity without additional clinical system so as to provide for the electron- the theory had not been tested before value. (O’Rourke 2014) ic exchange of health information to being put into practice, the transforma- Clinician dissatisfaction with EHRs improve the quality of care and to pro- tion from paper to electronic records is a result of too much information vide information on the quality of care. was begun in 2010 after passage of the ARRA. What we have now learned is being presented, much of it repetitious, The intended goals of meaningful use that all we have done is replace one set without any quick and easy way to compliance were: of problems with another. The problem differentiate the notes of one provider of “illegible paper records” transformed from another. The value of a written • Better clinical outcomes into “death by legible information word has decreased, because EHRs • Improved population health outcomes overload.” The lack of portability allow providers to insert large amounts • Increased transparency and efficiency of healthcare information became a of text into a record by cutting and past- ing pre-existing text. Some portions of • Empowered individuals problem where massive amounts of sensitive data could be stolen by hack- EHRs self-populate based on informa- • More robust research data on ers in seconds and dispersed around tion placed in other sections, increasing health systems the world. A problem with too little the amount of information on that page The goals of EHR technology were to: documentation of care was turned into but not adding any new information. On a problem of less time to provide clin- the other hand, the system may generate • Improve quality, safety, efficiency, and ical care. Serious questions have been many new pages even if only one click reduce health disparities raised as to whether or not the EHR mark is different. But the biggest prob- • Engage patients and family has succeeded in improving healthcare lem is that all the information looks the same. The ability to quickly and visually • Improve care coordination, and pop- delivery and outcomes. identify a document because of the ulation and public health THE EHR CLINICAL REALITY characteristic handwriting of a particular • Maintain privacy and security of provider, or the unique note format that The reality of the EHR revolution is patient health information a surgical service uses, is lost. Clinicians that electronic record created is vastly have to actually read large amounts of Meaningful use of EHRs was designed larger and more difficult for providers to text in small font to find the notes they to become part of the American health- work with than the same record when are looking for, then read the note. care system in a three stages: Data it was paper. One third of physicians Capture and Sharing (2011), Advanced report that EHRs caused deterioration Clinical Processes (2013) and Improved in clinical services. A similar percentage INCREASED INACCURACY Outcomes (2015). CMS provided incen- said that EHRs had a negative impact Dissatisfaction with EHRs also stems tive payments to healthcare providers to on clinical operations. In one study, the from numerous inaccuracies and encourage adoption of the EHR. These majority of oncologists complained that incorrect data that occur with their

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 15 | use. EHRs are not subject to regulato- users (Ong, 2011). Three components worry, “The application doesn’t have ry oversight, and FDA approval prior of usability consider how easy it is to what I need to document. Is it safe to use is not required. EHRs were use, how efficient the technology per- to use?” designed to accurately code for payment forms and ease of learning (Ong, 2011). The word “workflow” is important when not treatment. Usability directly impacts the end users considering EHR safety and usability. ability to properly utilize the technology As a general rule, less than 50% of It alters the way people render care, the in achieving safety, competent care deliv- EHRs are error-free. In one ophthal- steps that they follow, and how com- ery. Considerations include adherence mology cataract surgery EHR study, pliant they are with the new clinical to workflow, compliance with required only 35% of patient charts were cor- processes affected by the EHR. fields of documentation, adequate rect, with 59% containing omissions, integration testing prior to activation of 1% containing incorrect data and 3% Proper testing of the software is critical deployed technology, accurate interfaces, containing both admissions and data. step. The IS (informatics support) team and formalized usability assessments (Pullen 2014) A Veterans Administra- must subject the software to rigorous prior to implementations (Ong, 2011). tion study showed that 84% of patient testing of the application in all forms. A records had at least one documentation missed step may lead to errors. Here are error, and the average number of errors SAFETY AND USABILITY important testing considerations: per patient chart was 7.8. EHRs have The clinical reality of EMRs and their • Did the IS staff test the application? increased the amount of time needed usefulness in litigation are affected by How did they test it? to record a patient visit, but providers several hidden factors. The legal team • Did they work with their end users quickly learn that what they are looking may be unaware of the ways in which when designing the software? at in the EHR may not be true. these factors influence the information within the electronic medical error. Poor screen design may lead to medical EHR errors can arise from the com- Refer to Table 1 for an overview. Let’s errors. For example, the system may use puter system hardware and software, or dig a little deeper into these factors. open text boxes for weights - an empty errors can emanate from the informa- box into which a healthcare provider tion put in by system users. Erroneous enters a weight. Consider a situation in ADHERENCE TO WORKFLOW quick clicks can create long-lasting which physician #1 entered the weight errors. Cutting and pasting to save AND COMPLIANCE in kilograms. Physician #2 reviewed time and to create the appearance of There may be flaws in the software the weight on a different screen, but the attention to detail creates both infor- design. Some vendors’ software is not unit of measurement was not indicat- mation overload problems and allows very easy to use and does not foster a ed on the second screen. The second incorrect data to propagate throughout safe look or feel. There are open fields physician ordered the wrong dose of the record. EHRs are dependent on the that could be left blank or there are not medication, assuming that the weight data entered by its users. Just because enough drop-down fields. Users may was in pounds. The system did not alert information looks neat and correct doesn’t have any bearing on the accuracy Table 1. Factors in failure: Common problems with EHR elements of the information displayed. Wrong data is entered or copied into the system Computerized Clinical Decision Bar Code Technology Provider Order Support Medication Related looks exactly the same to the EHR as Entry (CPOE) Administration the correct data. (Chesanow, 2014) Inexperienced Non-adherence to Torn, soiled, Multiple passwords end user computerized alerts wrinkled labels All individuals have experienced the Data overload Clinician reminders, Override medication Insufficient difficulty associated with a poorly advice tools administration, avoids interface design, designed or “not user-friendly” items. scanning meds drop-down menus, documentation fields Poorly designed items cause end user Difficulty documenting Reporting methods Equipment failure Loss of connectivity, frustration, variation in use, and errors. and communicating system slowness Imagine the impact of poorly designed using the EHR Resistance to comply Compliance with Incorrect or Lack of EHRs that are difficult for end users to with CPOE, use order guidelines, order sets tampered wristband application testing properly document patient care. sets, medication reconciliation Usability is a term that refers to the ease Time consumption, Documentation Incorrect medication Duplicate order of use of information technology by end less time with patient templates or dose dispensed entries

| 16 | THE JOURNAL OF LEGAL NURSE CONSULTING the physician of any missing data. It did not request him to specify 150 pounds People can become too reliant on EHR vs. 70 kilograms, so it failed to alert the features that drive decision-making. But provider the measurement was missing. as we know in the litigation field, nothing Obscured information is another design error. For example, the physician pre- replaces the valuable thinking skills of a scribed an additional 3mg of Coumadin to equal 6mg total. A second physician human being. reviewing the medical record was unable to see the 6mg had been adminis- tered. After hovering over the cells the physician saw a pop-up showing the clinical decision support system. For over-reliant on technology. As we know additional 3mg that were given; it was example, DVT (deep vein thrombosis) in the litigation field, nothing replaces hidden. This could have resulted in a orders should follow DVT screening the valuable thinking skills of a human potential error of re-medication. When upon admission or at other points in being. there is a lack of visible data, patient a hospitalization. If the provider does safety depends on the end user remem- not use the standardized order sets As judged by conversations with clini- bering and looking for these extra steps and the alerts are built off of that, cians and internet discussion groups, to find data fields. the provider may forget to order the many people are very frustrated with the prophylactic medication. amount of time that it takes to get into INEXPERIENCE, DATA the application and to learn it. There OVERLOAD, AND Not every vendor approaches software could be interface issues. There could RESISTANCE the same way. Providers who have be delays. Any time a facility upgrades privileges at more than one healthcare or standardizes procedures there could There are many senior physicians who facility must be aware of the nuances of be glitches in the system. There may have to attend basic computer classes sev- each system. Passwords and procedures be delays in response times. A delay in eral times just to learn how to use a mouse may be significantly different. If the health care seems like hours when there and a keyboard. EHRs are designed for provider is unfamiliar with documen- is an immediate need for information. improved communication, but some peo- tation steps, the system may create a The system application slows during ple may not write their notes well if they’re block. The software has the ability to peak use. not templated out. The providers may not do hard stops that prevent a provider know how to enter data in those specific from continuing to document until a data fields, so missing communication can NOT ACTIVATING EVIDENCE step is completed. The software may be a problem. BASED PROTOCOLS have a soft stop, a message that alerts Evidence-based programs can be EHRs display a tremendous amount of the provider, who can override it and embedded into an EHR. These reflect data. Clinicians look at this data elec- continue documenting. Aware of the the standard of care for how clinicians tronically. It can be overwhelming; they risk of irritating the providers, the are to provide care. Although healthcare often cannot find information. software designers may have included a providers may activate these, they may low alert specificity, one that is not really not be familiar with all that is available Many physicians are concerned with sensitive. Oftentimes the organization or applicable. Activation of the evi- the possibility of a standardized order may do this because they don’t want to set for all the orders. This is a cause dence-based programs may create flow get the providers angry with multiple of heated contention among physi- sheet rows in the documentation. For stops that, if present, would contribute cians. If they do not like the order example, at 7:00 PM, a nurse performs to ensured safety. sets that were developed, they won’t a nursing admission assessment of a use them. Alerts are built directly off patient with pneumonia and sepsis. of the order sets. If physicians don’t DEPENDENCY ON The EHR has evidence-based practice use order sets and they choose to just TECHNOLOGY guidelines, but it’s 11:00 PM. He’s really write single order entries they’re not Many people may say, “You know what, tired; he leaves without activating them. going to see the alerts. This short- everything is in the computer. I don’t The next nurse comes on at 11:00 PM. cut bypasses the safety features of a need to think. I’m good.” They become She’s busy and she does not think about

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 17 | the evidence based practice guidelines. to ensure they are not overriding the ADMISSIBILITY: POTENTIAL Then the day shift nurse comes in at system. The wristband might be off, PROBLEMS OF EHRS AS 7:00 AM and says, “Oh my, this patient or the staff might be too busy, or the BUSINESS RECORDS has pneumonia and sepsis. My guide- scanner might work correctly. Overrid- In light of all of the design and use consid- lines aren’t in and I don’t have all the ing the medication barcoding process erations just presented, one can question appropriate documentation filled in.” results in deactivating the alerts that the admissibility of an EHR as a business Twelve hours have gone by without the would warn the provider that the record. Medical records are traditionally appropriate documentation. wrong medication or patient has been admissible as evidence in legal actions as a selected. The scanner can also mal- Hearsay Exception for Records of Regu- BAR CODING MEDICATION function. Devices may be attached to larly Conducted Activity under the federal ADMINISTRATION (BCMA) medication carts or the walls in the and state rules of evidence. See e.g. F.R.E. In this commonly used system, medi- room. They can get dropped. They can 803 (6). The fundamental bases for this cation administration is documented get thrown in the laundry or left on hearsay exception are that the statement directly into the EHR. The process is the cafeteria trays. They can be miss- was made in writing made at or near the connected to multiple interfaces such as ing. They are very expensive. time of observation, by a person with pharmacy orders and the MAR (Med- actual knowledge, in the regular course of ication Administration Record). The TRAINING business and regular practice, unless the nurse scans the bar code on the medi- CONSIDERATIONS sources of information indicate that the cation and the patient’s wristband. The information is not trustworthy. Insufficient training may result in errors. medication has to be correctly bar-cod- Inadequate training results in incomplete ed by pharmacy and the patient has to The contemporaneous requirement for have the appropriate wristband. and inaccurate documentation, lack of the business record exception may be compliance, medical errors, and overre- difficult to fulfill with an EHR. Data Although BCMA is designed to reduce liance on technology. Critical thinking entries made before and after the point errors, workarounds (shortcuts which errors occur, with failure to identify sub- of care are listed along with current point subvert the safety features) are com- tleties. Some facilities have dedicated staff of care data. When a provider cuts and mon. For example, bar code labels on for training, whereas in other facilities, pastes information from an earlier part medications and wristbands can be torn, the Informatics Support people provide of the record, or from a prior record of wrinkled, missing, soiled, or covered training and have many other responsibil- the same patient, it lacks the contempo- with another label. Many times pro- ities. When lack of training could have raneousness of the data contemplated by viders will print extra labels. They may contributed to a medical error, some of the the rule. See generally Drury B, Gelzer have a whole sheet of labels so that they relevant questions to ask include: R, Trites P, Electronic Health Records can increase the speed of scanning. They Systems: Testing the Limits of Digital might say, “I have four medications to • How are the end users trained? Records Reliability and Trust. Ave Maria give. I’m going to scan four times on the • Is the training environment built Law Rev. Vol. 12:2 pp.257-289 (2014). labels and I’m going to scan my medi- correctly for them to go into a play- The person with actual knowledge cines. I’m going to put them altogether ground environment and practice? in a little cup and take them to the requirement for an EHR to be admissible • Do they have available training room.” This practice skips the safety under the business exception rule could materials? check of scanning the patient’s wrist- also be challenged. When patient history band at the bedside. • Are they going to classes? is copied and pasted from a prior encoun- ter, instead of being elicited from the • Are they going to webinars? Providers may affix bar code labels to patient or other provider directly, the per- desks, walls, cabinets, and scanners. • Do they have access to tips and tricks sonal knowledge requirement is not met. They may wear them around their about the EHR? The author of the information in data that wrists and in their pockets. Providers • What compliance standards and is copied and pasted may be unknown. may place these labels in multiple places guidelines are in place? If the sources of information indicate to make it convenient, but this subverts • Are there performance-monitoring safety features. that the information is not reliable, then measures in place during and after the business record exception should not The clinical staffers need to be moni- training? apply. Studies have shown that there is tored once barcoding goes into effect • Are managers watching over this? a high input error rate in EHRs. Some

| 18 | THE JOURNAL OF LEGAL NURSE CONSULTING errors are easy and obvious to detect, In order to efficiently receive and use better clinical outcomes, improved popu- such as the 83-year-old lady whose age is medical information from an EHR, you lation health, increased transparency and listed as 38, but not all. There is no FDA first have to make it electronic again better efficiency in healthcare. The reality approval for EHRs as there is for medical by scanning the documents into your is that accuracy of EHRs is dependent devices and tests. There is no systemat- computer system. In order to do that, on its clinical users. Until we find the ic accuracy testing of data integrity in one needs a top-quality, high-volume right balance between the human and the EHRs. Audit trails are not required for scanner with a professional-grade PDF technical component of EHRs, dissatis- EHRs used in patient care. Since errors software program. The system needs to faction with them will continue. can be found in the majority of EHRs, a be able to scan both sides of the docu- court could find a basis for disallowing ments at once and any eliminate blank REFERENCES pages from the saved scanned PDF file. the admission of an EHR into evidence, Bell J., Doctors Not Using Electronic Medical File formats must be kept to a minimum if an attorney challenged its veracity. Records Faced With Payment Cuts (http://www. acceptable size so as to not use over- wallstreetotc.com/doctors-not-using-electron- From a practical standpoint, challenging whelming amounts of data storage space. ic-medical-records-faced-with-payment-cuts/ the veracity and admissibility of ERHs Condensed PDF files and a print setting 213502/) Retrieved 3/3/2015 on a regular basis would be self-defeat- of 300dpi black print allow voluminous Centers for Medicare and Medicaid Services, ing. The time and cost of authenticating documents to be scanned into relatively Payment Adjustments & Hardship Exceptions the author of each data entry, along small files compared with other settings. Tipsheet for Eligible Professionals (August 2014) with the time, location and personal http://www.cms.gov/Regulations-and-Guid- An EHR printout does not necessar- knowledge concerning that data entry ance/Legislation/EHRIncentivePrograms/ would be overwhelming. Rather than ily show all of the patient’s healthcare Downloads/PaymentAdj_HardshipExcepTip- use EHRs’ inaccuracies to prevent the information, only that which is displayed SheetforEP.pdf Retrieved 3/3/2015 on the screen to be printed. EHRs are admission into evidence as a business used on computer terminals in real time. Chesanow N, 8 Malpractice Dangers in Your record hearsay exception, it is more EHR. Medscape Business of Medicine http:// Often there are underlying screens of useful to selectively use inaccuracies in www.medscape.com/viewarticle/828403 (Aug information that are not visible on the an EHR in support of a motion to allow 26, 2014) Retried 3/5/2015 main screen. While it is unrealistic for an investigation into a critical aspect of the attorney to review each client’s medical Drury B, Gelzer R, Trites P, Electronic Health case in order to confirm its accuracy. If Records Systems: Testing the Limits of Digital record on the EHR on which it resides, a reasonable degree of unreliability can Records Reliability and Trust. Ave Maria Law there are times when the facts of a case Rev. Vol. 12:2 pp.257-289 (2014) be demonstrated, a court should allow indicate that additional information may discovery of the underlying metadata exist. In such situations, it is advisable to Meaningful Use. Centers for Disease Control and audit trail that shows all the partic- engage an EHR consultant to assist in and Prevention. http://www.cdc.gov/ehrmean- ulars about a specific data entry and any ingfuluse/introduction.html (2014) Retrieved determining the type of information that 3/3/2015 changes to it (Terry 2014). may not be visible on the main screen and to actually go to the facility and Ong, K. (2011). Medical Informatics An DISCOVERY OF EHRS analyze the patient’s EHR file. The EHR Executive Primer Second Edition, Healthcare consultant knows what to look for. Information and Management Systems Society Obtaining the EHR for a personal injury (HIMSS). Chicago client in litigation is still done by way of providing an executed HIPAA-compliant CONCLUSION O’Rourke KM, EHRs Not Living Up to the paper authorization form for release of Hype. Medscape Oncology http://www.med- EHRs held out the promise of faster, scape.com/viewarticle/833224 (Oct. 20, 2014) medical records. Various state rules apply better, and more coordinated healthcare Retrieved 3/3/2015 regarding maximum costs for production and, on this promise, became a regulato- and other specifics. The irony of EHRs is ry requirement for healthcare providers. Pullen LC, Human Error Seeps into Electronic that the requested electronic records are Medical Records. Medscape Medical News Unfortunately, theory and practice are Conference News http://www.medscape.com/ printed out on paper and sent by mail. not the same. The problems with paper viewarticle/834566 (Nov. 4, 2014) Retrieved There is nothing electronic about the medical records have been changed into 3/3/2015 electronic records received by an attor- new and different problems with EHRs. Stage 2 Meaningful Use Fact Sheet. Centers for ney or legal nurse consultant. Although Data overload, errors in data entry, and Disease Control and Prevention. http://www. imaging studies are now almost exclusively design and usability issues make the cdc.gov/phin/library/PHIN_Fact_Sheets/ provided in electronic format on disc, not EHR susceptible to inaccuracies and Stage%202%20Fact%20Sheet-09_03_2013. so with the paper records. challenge. The goal of EHRs is to allow pdf (2012) Retrieved 3/3/2015

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 19 | FEATURE

Terry K, EHRs Not Reliable for Legal Cases, certified in diagnostic radiology, is a Becky Rufo, DNSC, RN Experts Say. Medscape Medical News, http:// graduate of Columbia University School CCRN has served in a www.medscape.com/viewarticle/832822 of Law and has a Masters of Business system leadership role for 6 (Oct. 3, 2014) Retrieved 3/3/2015 4 Administration in Health Care at Colum- Electronic Health Record bia Business School. Armand founded implementations in a large Britcher Leone & Roth with Mindy Roth Chicago health system. She Armand Leone, Jr, MD, and Drew Britcher in 2000. led the implementation efforts of two JD, MBA is a licensed different Tele-ICUs in large Chicago health physician and attorney systems and received national recognition responsible for medical Patricia Iyer, MSN, RN for excellence. She is an Associate malpractice, pharmaceutical LNCC has reviewed Professor in a Graduate Nursing Program and medical device product thousands of medical in Nursing Informatics. Dr. Rufo has 30 liability matters at Britcher Leone & Roth records since 1987. As an years of nursing experience in clinical, in Glen Rock, New Jersey. He is a Fellow independent legal nurse leadership, organizational development, of the American College of Legal consultant, Pat founded education, and informatics. She has Medicine and of the New York Academy Med League Support Services, Inc., which achieved national recognition in publica- of Medicine. In addition to his profession- she owned for 28 years. She currently tions and presentations and won two al practice, Armand has participated in provides legal nurse business coaching awards for excellence in Telemedicine. hearings before the US Olympic Commit- services. Pat is past president of AALNC. tee, the American Arbitration Association Contact her at [email protected] or on athlete rights issues. He is a graduate through her websites, www.patiyer.com of New York Medical College, is board and www.LNCAcademyinc.com.

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| 20 | THE JOURNAL OF LEGAL NURSE CONSULTING FEATURE

Audit Logs Scott Greene, CEO, Evidence Solutions, Inc.

Keywords: EHR, EMR, chart audit, audit logs, audit trail, data breach, health records

Audit logs and metadata are key to proving when changes were made in a patient’s chart. This article will discuss data breaches, audit logs, their requirements, nature, and security in the healthcare industry. This will also discuss how to ask for records, how to recognize the ease by which records can be altered.

AUDIT LOGS: mandate that electronic health records Security Knowing the identity and, usual- THE REQUIREMENTS FOR (EHR) technology meet certain audit ly, the location of the person who viewed PATIENT PRIVACY log requirements. Changes and actions the record (generally an IP address). to the patient record must be captured, Laws are firmly in place to guide n addition to the meaningful use including dates and times of the actions, healthcare administrators and staff on audit log requirements, the HIPAA user identification, and ID of the patient ethics surrounding medical records and ISecurity Rule, HITECH Act, and record being accessed. the Joint Commission each have specific patient confidentiality, including use of audit logs and audit trails. Failure requirements pertaining to audit logs WHAT DOES ELECTRONIC and patient privacy. to follow the rules can result in hefty AUDIT TRAIL MEAN? penalties, including jail time. Electron- The Office of the National Coor- An electronic audit trail in the context ic audit trails for EMR access points dinator’s 2014 Health Information of electronic medical records (EMR) is should be designed to ensure confidenti- Technology Certification programs used for the following reasons: ality, compliance, and authentication.

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 21 | Medical billing Ensuring accurate in the record. Each change to a patient’s gives the log reviewer a clue as to where billing, including the proper charge for record should have a single line with the data originated. services or procedures. a date and time to show its creation and any additions and/or changes. Role This field has to do with securi- Medical bills were computerized long A typical time stamp looks like this: ty permissions, indicating a group of before medical records were. But with “11/20/2011 16:42:05 EST.” It is users with particular access rights to integration, comes automation. When important to adjust the date and time each medical record. When this field is an electronic progress notes, surgical if the date and time stamp is related to filled in with “Physician,” for example, notes or discharge treatment notes is another time zone. In this case the time the person who logs in to this session entered into these systems along with zone for this entry is “EST” or Eastern has the access and entry permissions the pre-determined diagnosis code, the Standard Time. If the facility where the assigned to the “Physician” role. Typ- procedure code is automatically sent to entry occurred is in another time zone, ically, a physician can see everything the billing department. then an adjustment will need to occur in the patient’s medical record. A user whose role is “Radiology Technologist,” Data gathering Obtaining data for public to determine the local time. health reporting and medical research. however, may only be able to see infor- Facility This generally refers to the facil- mation about the patient’s radiology Health care organizations are some- ity or department where the patient is images and results. A given organi- times required by state and federal being treated when the entry is made. It zation’s roles can be different from public health agencies to gather data can be an abbreviation for a facility such another organization’s roles. to help diagnose, track, and remediate as a hospital or it can be a department disease outbreaks. Reporting time for within a given facility. For example, a Device, Device Name, Server These this type of information is usually quite sample facility field may contain “GH.” fields refer to the computer or device short. Electronic audit trails can also be The EMR system likely has another used to access the record. Normally utilized for medical research purposes, reference table or list that can translate there are two: One contains an ID e.g., to help discover the etiology of a “GH” to “General Hospital.” for the device that the user is actually possible medication reaction. using to view or enter into the medi- Nursing Unit Typically this is facil- cal record, e.g., a terminal on a floor, ity-specific. It may be a department a handheld device, or a remote access. SO YOU WANT AN AUDIT within the facility if the EMR system The second field indicates which com- LOG. WHAT DO YOU NEED uses the Facility field as a location, e.g., puter system inside the organization’s TO ASK FOR? “EMRM.” As with the Facility field, you Information Technology department Typically law firms ask us for an “audit will probably need a reference table or is being accessed by the device listed in log” or an “audit trail” by patient or med- list to translate this entry from a code to the first field. ical record number (MRN) for a given a recognizable location. time frame. On occasion, we will see the User, User Name, Person, Personnel Application, Module, Sub-System time frame requested as “all,” which is Name, etc. This is most likely the user This field generally holds information intended to net the patient’s entire log who is making the entry. These fields about which module or subsystem of while in the care of that organization. are usually populated with either the the EMR system the caregiver is using to enter information. These fields can However, it is usually more productive person’s login ID, e.g., “jdoe,” or name, to ask for specific information, allowing e.g., “John Doe” or JDoeRN.” contain broad entries such as “Micro- for an “including but not limited to” dis- biology” or “Radiology,” or they may be However, these fields may also contain claimer. Each EMR system is different more descriptive such as: “Microbiology: something non-obvious like, “System,” and can hold different information. If we Result Entry” or “Diagnostic Imaging: “Imaging Server,” or “Chart Server.” know which EMR system is in use, we Transcription.” Typically this indicates some sort can typically generate a list of the fields of automated access to the medical Event, Event Name, Event Type, Task that we want. record to add or create information. These fields are usually abbreviations This occurs when a larger facility uses or codes that relate to the screens that WHAT’S IN AN AUDIT LOG? different computer systems in different the user is using to view or make entries Time stamp The time stamp is a critical areas (e.g., laboratory, pharmacy, central into the medical record: Examples piece of the EMR audit. It indcates the supply), and these disparate systems include: “View Encounter: Open Chart,” date and time that something occurred communicate with each other. This and “Lab Inquiry: View Results.”

| 22 | THE JOURNAL OF LEGAL NURSE CONSULTING WHAT IS THE USE OF AN AUDIT LOGS ARE EDITABLE? • St. Joseph Health System, AUDIT LOG IN LITIGATION? SAY IT ISN’T SO! Suwanee, GA Audit logs can help bolster either plain- Many experts declare that an audit trail Names, dates of birth, Social Security tiff or defense claims about whether represents everything that happens numbers, and addresses of approximate- procedures were performed at the with a medical record. Some will swear ly 405,000 people at risk. times that the clinician states they were that audit logs cannot be changed. The • Montana Health Department, performed. In addition, audit logs can truth is that in many cases audit logs Helena, MT sometimes show if someone who was can be manipulated and altered. This Names, addresses, dates of birth, Social involved with the patient’s care accessed, manipulation and alteration, then leads Security numbers, bank account infor- altered, or modified data when or where to the conclusion that the audit log may mation, and clinical information from a they shouldn’t have. not fully represent everything that has 1.3 million-person database. happened with a medical record. • Anthem Health Insurance, Example: Alteration In December 2013, the Department of Indianapolis, IN In November 2011, a bacteriological cul- Health and Human Services’ Inspector ture was done a technician in the hospital Names, addresses, dates of birth, Social General’s office surveyed almost 900 Security numbers, email, salary and laboratory as requested by the hospital hospitals. The survey, which had a 95% Emergency Room physician. Preliminary employment information from approxi- response rate, found 44% of the hospi- mately 80,000,000 accounts. results delivered to the Emergency Room tals who answered reported having the • Premera Blue Cross, were given as “not conclusive” in the record, ability to delete their audit logs. Anoth- Mountlake Terrace, WA and did not indicate that the patient had er 33% could disable the audit logs, Group A Streptococci. Neither did several while 11% could edit them at will. Unknown (at this time) but thought printouts of screens and the chart include to include: names, dates of birth, any mention of the Group A Strep. The Our forensic experts believe that the per- Social Security numbers, addresses, patient outcome was not favorable, and centages could actually be much higher. e-mail addresses, phone numbers, identification numbers, bank account or payment information, and claims information, including clinical Data, including audit logs, can be information from approximately changed. A printout of the medical record 11,000,000 accounts. along with audit log won’t show that data EMRs should be protected and secure. It is imperative to protect EMRs from had been manipulated. unauthorized outside access and reliable data trails are necessary in order to make sure that only employees and contractors who have a “need to know” can access them. HIPAA specifically in 2013, an action was brought alleging The reason is relatively simple: Audit logs requires that only authorized users have failure to diagnose this infection. are data. Data can be created, manipulat- access to medical records. ed, or changed. If the same changes are Although the initial audit of the made to both the patient’s medical record However due to their online status and patient’s record was originally limited and to the audit log(s) who would be the our hyper-connected society, EMR to the 2011 time frame, a later audit log wiser? A printout of the medical record systems are exposed to the Internet. indicated a change had been made to the along with audit log won’t show that data This makes these systems vulnerable “Bacteriological Results” field in 2013. had been manipulated. to hackers. The audit log and the investigation into Health care leaders need to be more the data were expanded. Metadata in HEALTH DATA diligent than they have been in terms the audit log and in the EMR system SYSTEM BREACHES of security. While external attacks are disclosed the exact date and time when With significant data breaches in the last becoming more common, other threats the lab clinician (who was identifiable) year, securing EMR data is critical. These include lost or stolen laptops and unau- changed the information in 2013. data breaches were recently discovered: thorized access to EMR records. The

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 23 | health care industry needs to defend Medical records can contain names, Social against sophisticated cybercriminals who seek critical medical data to com- Security numbers, eligibility information and mit fraud or turn a profit. insurance identification numbers that could HACKS AND DATA be used to access care, and credit card and BREACHES DON’T COME JUST FROM THE OUTSIDE banking information. Kayne West and Kim Kardashian had their baby in the Cedars-Sinai Hospital in Los Angeles, CA. on June 24, 2013. Between June 18 and June 24, 2013 WHY ARE MEDICAL According to a report published by Kim Kardashian’s medical records were RECORDS SO VALUABLE? AllClear ID, the percentage of identity theft doubled between 2011 and 2012 inappropriately accessed. The hospi- While each hack and data breach is data for children 5 and under. The tal fired five individuals who accessed unique, personally identifiable information company says: “10.7% of the children Kardashian’s medical records outside of (PII) may be divulged. This may include scanned from our data were victims of their scope of employment. In addition bank accounts, credit card accounts, and identity theft. This is 35 times greater to the five fired for accessing her records, online buying accounts. In other cases, than the rate of identity theft seen in a sixth person was fired for accessing hackers only end up with email addresses adults in the same population.” the records of 14 other patients in that and passwords. EMR and EHR data same time period. breaches appear to have the highest value to hackers. While values vary, several SUMMARY In October of 2013, the Allina Health sources we found indicate the following: Requesting and reading audit trails System in Minnesota notified approx- and logs is a specialty. If something just imately 3,800 patients that one of its • Social Security numbers from isn’t adding up, consider consulting a clinic medical assistants had improperly $0.25 to $3 each computer forensics expert with experi- accessing their protected health infor- • Credit card numbers from ence in EHR to be sure you are getting mation (PHI) over approximately three $2 to $9 each a clear picture. years between February 2010 and Sep- • Identities from $5 to $10 each tember 2013. The record system, which • Electronic medical records from RESOURCES covers all of the Allina Health System, $10 to $1000 each Meaningful use audit logs: http://www.cms. allowed the employee to access not only gov/Regulations-and-Guidance/Legislation/ records at the clinic location, but also Not only do medical records contain EHRIncentivePrograms/downloads/Stage2_ records from other locations within the PII such as name, address, and Social EPCore_9_ProtectElectronicHealthInfo.pdf organization. The employee in this case, Security number, they also contain HIPAA Security Rule: www.hhs.gov/ocr/priva- accessed patients names, dates of birth, eligibility information and health cy/hipaa/understanding/srsummary.html insurance identification numbers clinical health data, health insurance HITECH Act Rule http://www.hhs.gov/ocr/ coverage information, and partial Social which could allow someone to receive privacy/hipaa/administrative/enforcemen- Security numbers. “We deeply regret that free medical care, including surgery. trule/hitechenforcementifr.html 4 this occurred and want you to know we They may also contain credit card and are committed to protecting the privacy banking information. of our patients’ personal information,” Further, since children’s EMR records Scott Green is CEO and the Allina website said. “To help prevent are included with adults’, children’s Senior Technology Examiner similar incidents from happening in the records are particularly valuable to at Evidence Solutions, Inc., a forensics company founded future, we are evaluating our policies cybercriminals because their lack of a related to protecting patient informa- in 1982. ESI provides credit report and bank account makes consulting, industry expert tion, examining our computer security it difficult to monitor them for identity witness, and testimony services for digital programs and continuing to educate theft. It is possible for a child’s identity evidence, law enforcement and security, employees on their obligation to main- to be exploited for years before the fraud and heavy trucking investigations. He may tain the privacy of patient information.” is uncovered. be contacted at 866-795-7166.

| 24 | THE JOURNAL OF LEGAL NURSE CONSULTING FEATURE

Follow the Audit Trail May 2014 - Jennifer Keel

Reprinted with permission of Trial (May 2014), Copyright American Association for Justice, formerly Association of Trial Lawyers of America (ATLA®)

very activity and entry in a electronic medical record (EMR), the on your computer. With a few clicks, patient’s medical records. These system makes a contemporaneous you can view its properties — that Eonline logs can provide crucial record of that activity as it occurs. This information is metadata about the doc- evidence in your client’s medical mal- audit trail provides direct evidence of ument. If you open the document, even practice case if you know how to obtain exactly what was done — when, where, without making changes, the metadata and use them. and by whom — to a patient’s EMR. will change. Similarly, the audit trail is Every time a user views, edits, prints, Another way to think about the audit the metadata for a patient’s chart that deletes, downloads, exports, or other- trail is metadata about the patient’s chart changes every time the chart is accessed wise manipulates any part of a patient’s itself. Consider an ordinary document or altered.

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 25 | The use of EMRs has been on the rise The documentation systems other since 2004, when President George W. Bush launched an initiative to comput- departments use may not show up on erize health records.1 This progression advanced exponentially when the an audit inquiry of the main clinical Centers for Medicare and Medicaid documentation system. Services offered incentive payments to clinicians and hospitals when they used electronic records to achieve improve- ments in patient care.2 Along with this In 2009, the Health Information Tech- for it, but today you can check the audit increasing use came more concerns nology for Economic and Clinical Health trail. It may reveal conclusively that no one about privacy and security. Despite (HITECH) Act was passed to promote printed discharge instructions for your these concerns, audit trails have meaningful use of health care technology.5 client before she left the hospital, but that become an integral part of the medical Unlike older laws, which were written after suit was filed, someone accessed the system and medical malpractice liti- with paper records in mind, newer laws chart and printed the instructions, just gation. They are an important tool at contain provisions addressing techno- days before they were disclosed to you.7 your disposal, but first you must know logical advances in health information. how to obtain them and use them to The HITECH Act specifies that EMR We have all taken depositions where your client’s advantage. systems must satisfy certain requirements, providers claim to have a clear recollec- tion — years later — that they made HIPAA set the national standard for such as recording access to patient records, key entries contemporaneously and maintaining patients’ medical informa- showing who viewed or changed informa- were at your client’s bedside during tion, including electronic data. One of tion, when this was done, and from what every important event in his or her care. its purposes was to ensure that medical location. Together, these statutes provide Don’t believe them? Get the audit trails records could not be altered without a legal framework that requires organiza- showing which computer terminals they detection, to “protect the security and tions using EMRs to track and maintain a 6 used to enter information and when. privacy of individually identifiable log of all access to electronic records. You may learn that all the entries were health information,”3 but the statute made hours later, and that a nurse was in alone was insufficient to fully address EVIDENTIARY CLUES another patient’s room entering infor- the expanding range of issues inherent What can you learn from an audit trail to mation into someone else’s chart when in the transition to completely elec- help your client? The possibilities abound. he or she claims to have been with your tronic systems. In 2003, the HIPAA Suppose your client was discharged from client. In fact, audit trails can be run to Security Rule was passed. It requires the emergency room without discharge show a certain care provider’s activity regular monitoring of system activity, instructions, a key issue in your case. and do not have to be confined to a including audit logs and access reports, Many months into litigation, a copy of particular patient. This might be done by IT personnel or compliance officers discharge instructions appears for the first to demonstrate, for example, patterns on a quarterly basis (if not more fre- time. The hospital tells you that it existed of documentation failures or suspicious quently), as well as the implementation all along and was inadvertently omitted narcotics handling by a particular nurse.8 of hardware, software, and procedural from every certified copy of the chart mechanisms to record and examine previously produced. In the past, you had If you want to know whether the nurse system activity.4 little choice but to take the hospital’s word who claims to have charted contempo-

1. George W. Bush, Address, President Bush Discusses Quality, Affordable Health Care (White House, Washington, D.C. Jan. 28, 2004), www.georgewbush-whitehouse.archives.gov/news/releases/2004/01/20040128-2.html. 2. 42 C.F.R. §495.2—Standards for the Electronic Health Record Technology Incentive Program. 3. Smith v. Am. Home Prods. Corp. Wyeth-Ayerst Pharm., 855 A.2d 608, 611 (N.J. Super. L. Div. 2003); see also R.K. v. St. Mary’s Med. Ctr., Inc., 735 S.E.2d 715, 720 (W. Va. 2012), cert. denied, 133 S. Ct. 1738 (2013). 4. 45 C.F.R. §§160, 162, 164 (2014); 45 C.F.R. §164.308(a)(1)(ii)(c); 45 C.F.R. §164.312(b). 5. 42 U.S.C. §300jj (2014), §17901 (2014). 6. See e.g. 42 U.S.C. §1320d (2014); see also 45 C.F.R. §§160, 164, 170. 7. See e.g. Pl.’s Mot. to Compel Prod. of Audit Trail Docs. at 8, Hand v. Girard, 2012 CV 353, (Colo. Arapahoe Co. Dist., July 19, 2013.) 8. Nimoh v. Allina Health Sys., 2011 WL 4008313 (Minn. App. Sept. 12, 2011).

| 26 | THE JOURNAL OF LEGAL NURSE CONSULTING raneously at the terminal in your client’s is irrelevant, or that you’re not entitled mation can be altered once it is exported room was telling the truth, focus the to it. I have not yet encountered a claim to a spreadsheet. Key items might be audit request on that nurse without lim- of privilege in response to an audit trail deleted or changed before the document iting it to your client. In that instance, request, but that too may be inevita- is produced in discovery. Insist on the you might ask for the audit records that ble. None of these objections holds up unedited, original electronic format show every time that nurse accessed under close scrutiny.11 of the document, and have a forensic the system from any terminal during expert examine it to ensure no one Know what you are seeking, and tailor a certain period. Defense counsel will tampered with it. Do not accept other your requests. Audit trail records are balk at this and claim that your request formats, such as a PDF document. violates other patients’ HIPAA rights, obtained by querying a database with but the audit records can be pulled various search terms—such as infor- Be wary of audit trail records that omit without patient identifiers if the query mation identifying a patient, a provider, evidence of EMR access at the time specifies that, or they can simply redact a location in the hospital, a particular the audit report is run and/or after the the confidential information.9 EMR system, a date or time span, and patient was discharged. a specific visit. The fewer parameters For example, suppose your client was You might discover that someone entered, the wider the inquiry will be. discharged from the hospital on Dec. accessed or altered your client’s records For example, your client’s name and date 1, 2012, and you request a copy of the for inappropriate reasons, and reviewing of birth may produce a large pool of 10 patient’s records for that visit today. audit records can reveal such activity. information, but adding a date of care The audit trail should show that the Or, you may discover that people whose would narrow the results. Specificity in records were accessed, viewed, and names do not appear in the medical your search terms is likely to increase printed shortly after your request record or were not disclosed as witness- your chances of success. es accessed the chart and had a role in to be produced. It should also con- providing care. They may be unit clerks Before making any discovery requests, tain other entries concerning billing, responsible for clerical duties, nurses obtain a copy of the hospital’s poli- doctors’ post-release notes, and other assigned to other patients who stepped cy manuals to improve the odds of housekeeping matters. If the audit trail in to lend a hand, or technicians in receiving the audit records. These simply ends at the time your client was other departments, such as radiology. manuals contain policies that specifi- discharged, you know that something Hospital employees may have made cally address data security and auditing is missing. capabilities within the EMR systems. entries in sections of your client’s chart Also question audit records that lack Often, these policy manuals also that were never produced to you, such evidence of any EMR access from contain additional data about how the as a telephone log or radiology records the lab, radiology, pharmacy, or other facility is organized and what infor- system. A detailed timeline will begin to departments within a hospital. Many mation is available. Armed with this unfold in your client’s audit trail — as of the EMR platforms are “closed knowledge, you can tailor the language well as an inventory of witnesses and systems,” which means they cannot be in your discovery requests. It will be documents — that is not apparent from integrated with other systems in the far more difficult for your opponent the medical records alone. hospital. The documentation systems to claim they do not understand your other departments use may not show requests when you can refer them to AUDIT TRAIL PRODUCTION up on an audit inquiry of the main their own internal policies. Request the audit records you want clinical documentation system. Each in discovery, but be prepared to file Once you receive the audit trail docu- database that is not directly con- motions to obtain the information. ments, be skeptical. Although federal nected to the main clinical charting Defense counsel may deny that it exists, law prohibits editing the audit trail system must be queried as part of a argue that they cannot access it, that it records in the EMR system,12 the infor- records search.

9. Courts may order other patients’ identifying information be redacted. See Or. re Pl.’s Mot. to Compel Cir. at 3, Ruchotzke v. Roberts, 13-L-78 (Ill. Peoria Co. Cir., Jan. 22, 2014). 10. See Bryant v. Jackson, 2013 WL 5529322 (Mass., Suffolk Co. Super. Sept. 17, 2013); Yath v. Fairview Clinics, N. P., 767 N.W.2d 34, 38, (Minn. App. 2009). 11. See e.g. Pl.’s Mot. to Compel Prod. of Audit Trail Docs. & Def. Resp. to Mot. to Compel (Aug. 9, 2013), Hand, 2012 CV 353; see also Pl.’s Mot. to Compel (Nov. 27, 2013), & Def. Resp. to Mot. to Compel (Jan. 17, 2014), Ruchotzke, 13-L-78. 12. See 45 C.F.R. §170.302(s)(3) (2014) (regarding integrity of audit logs).

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 27 | DEPOSITIONS short, defendants know what you’re ask- The audit trail is the only objective account Once you have the documents, you ing for and how to provide it. They may of when your client’s data was viewed and may find that the complexion of your need to do it for Medicare or Medicaid, charted. The timing of when providers case changes. If you have witnesses who for internal purposes, in response to looked at test results or made entries have already been deposed, go back and concerns or complaints about HIPAA often becomes a critical issue. Just as the compare their answers to the evidence in violations, or for various other reasons. EMR provides a more accurate account the audit trails. Use those discrepancies to of what happened with the patient at the Defense counsel may argue that such a time in question than recollections years your advantage when deposing future wit- request is unduly burdensome for their later during litigation, the audit trail gives nesses. If you can obtain the documents client, but audit trail production is a a more precise snapshot of who manip- before deposing anyone, you have the simple database query usually done by ulated the record, wwhen, and for what option of either cornering a witness with IT staff, and it does not take clinicians purpose. If you cannot locate a provider, the information in the audit trail or letting away from their patient care responsibil- that provider’s audit trail may be the only him or her advance unaware through ities. Someone types in the search terms reliable “testimony” you can obtain. your questions to his or her detriment. and sets the search engine to work. The In either case, it is often surprising how completed report is exported into a Because providers cannot document many providers forget that their activity is format for use — usually a spreadsheet. every detail associated with patient care, monitored in the EMR. They will assert Your requests should always be for the the audit trail often fills in gaps about their clear recollection of a story that unaltered, native electronic format of the undocumented occurrences: when your serves their interests in almost every case, audit trail (not a printout). And, because client’s discharge instructions were without regard to whether your next line the files are electronic, there is no burden printed, when the doctor viewed test of questions may trap them in a lie. of printing a voluminous record. results, or whether he or she did so from home or at the patient’s bedside. Of all OVERCOMING OBJECTIONS The audit trail is not part of the medical the hurdles you may face in obtaining record. To the contrary. Because the audit You will encounter objections when an audit trail, the relevance objection trail is metadata about the medical record, should be the easiest to overcome. requesting audit trail records, and a few it is undeniably part of the record. In fact, of the most common are discussed here. it cannot be separated from the EMR, Discovery of audit trails is a relatively The audit trail is too burdensome to because every time someone accesses new and underused tool for plaintiff collect or produce. This is by far the first the record, a corresponding entry in the lawyers. In the future, audit trails may be and loudest objection, and it is simply database is generated, tracking access. routinely provided as part of a medical untrue — audit trail information is easy This data is an integral part of the record records request, but you need to know to collect and produce. Hospitals employ and provides direct evidence about the how to obtain them now. The effort will highly trained IT staff, including database care your client received from the facility pay off in developing cases for trial.4 administrators and technicians, whose and the individual medical providers. principal job is managing the hospital’s Although the audit trail will not provide databases and running queries against medical assessments, such as the patient’s Jennifer L. Keel, JD, is a them. Producing audit trail reports is an vital signs, it will tell you who charted shareholder at Burg ordinary function of this job. While the these observations; whether they were Simpson Eldredge Hersh & defense will try to portray your request as changed; and who viewed the informa- Jardine in Denver. She holds unique and bizarre and one that they have tion subsequent to its entry, printed it, or a BS (SCL) and Master’s in Intelligence and National little hope of being able to comply with, deleted it, and when. This data is a more Security Studies, was a paramedic for six accurate record about the care that was you are not the first person to demand years in a large urban area, and served as production of audit trails during litigation. rendered than the chart alone. a tissue procurement team leader for a Facilities using EMRs must keep these The audit trail is irrelevant. You can human parts and eye bank. She co-teach- logs and provide access to them as show how this evidence is pertinent es a class in medical malpractice litigation with the Sturm College of Law in Denver. required by law (and must demonstrate to your case in numerous ways. At a She has published articles on various compliance with these statutes to main- minimum, it can give you a list of every topics in medical negligence, and has tain their federal accreditation), so there person whose credentials were used to lectured in various continuing legal is already a maintenance and retrieval access the chart, which will reveal poten- education programs across the country. process in place for audit trails — which tial witnesses who were not apparent She may be contacted at jkeel@burgsimp- is described in the policy manuals. In from the records themselves. son.com or 303-792-5595.

| 28 | THE JOURNAL OF LEGAL NURSE CONSULTING FEATURE

Documented — But Not Done

Katy Jones, MSN, RN, LNC

Reprinted with permission from LNCTips.com, 2015

s nurses, we’ve all learned the can still lead to lawsuits. That’s because words because they will be in a bold phrase: “Not documented, many of these records use time savers, font, have a blackened circle in front of A not done.” The phrase implies such as auto-populating fields. For them, or otherwise stand out from the that if the caregiver didn’t document all example, a review of systems related to other terms. aspects of care, the care wasn’t per- a patient’s gastrointestinal history might If the patient has none of the listed formed. This phrase has been a boon to auto-populate as the following: signs and symptoms, the caregiver plaintiffs until recently. But I’m now see- Denies appetite changes, weight changes, doesn’t have to chart anything with ing plaintiffs file lawsuits claiming that dysphagia, nausea, vomiting, hemateme- some types of electronic record systems. documentation was done, but the care sis, bright red blood per rectum, melena, When reviewing the medical records, wasn’t actually performed. There’s asim - abdominal pain, colic, icterus, diarrhea, the LNC will see that the patient denied ple reason for this change in approach constipation, change in bowels, tenesmus, having any of the listed GI problems. by plaintiffs. And there are somebig hemorrhoids, rectal pain, hernia. implications for expert, in-house, and However, I’m now seeing lawsuits in independent legal nurse consultants. If the patient has any of the signs or which plaintiffs claim that caregivers symptoms listed above, the caregiver never asked the questions listed in the Thesimple reason for the change is identifies the words that describe the self-populated fields. In essence, we now electronic medical records. What I’m patient’s GI history. As a legal nurse have situations in which care has been now seeing is that good documentation consultant, you’ll recognize those documented but not done.

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 29 | How will plaintiffs prove that the care wasn’t done? They’ll do it the same way If documentation didn’t support a patient’s that defendants prove that they actually allegations, attorneys would decline a case. performed care that wasn’t documented: by verbal testimony. Now, with electronic medical records, LNCs Independent and in-house LNCs who must take an additional step: determine if work with plaintiff firms often meet with potential clients and then correlate the records themselves might be inaccurate. their allegations to the medical records. Until recently, if documentation in med- ical records didn’t support a patient’s allegations, attorneys would often forgo inaccurate documentation because of I visited Dr. X on February 18, 2015, I filing a lawsuit on the patient’s behalf. the two-week time lapse between the complained of pain in the lower left side However, with electronic medical two visits. Identifying inconsistencies of my abdomen.” The expert’s affidavit records, LNCs need to take an addi- between the records and the patient, would then include a statement such tional step, by trying to determine if the then reporting those inconsistencies to as, “According to the affidavit of patient records themselves might be inaccurate. the attorney are important actions for John Smith, he complained of pain in his For example, consider the following two the LNC to take. lower left side when he visited Dr. X on February 18. 2015.” scenarios. In the first scenario, a patient Experts for plaintiffs need to be visits his primary care provider (PCP) careful when using patient statements For years, I’ve said that verbal testimo- whose electronic medical record system as part of their opinions, unless the ny carries the same weight as written has self-populating fields. In the GI statements are part of sworn testimony. documentation, at least in the eyes of section of the history, the PCP’s records Several of the attorneys in the defense the law. I think we’re going to see more show that the patient denied GI signs firm where I work will challenge expert and more lawsuits that are based on and symptoms. However, the next day, pre-suit affidavits based on unsworn inconsistencies between plaintiff state- ments and electronic documentation of care. In other words, we’re going to see more lawsuits based on cases that were We can expect to see more lawsuits documented but not done. 4 that are based on inconsistencies between plaintiff statements and electronic Katy Jones MSN, RN, LNC has a clinical background in documentation of care. medical-surgical, telemetry, and critical care. She has taught nursing to baccalau- reate students as an assistant professor and nursing standards the patient visits the emergency room plaintiff statements. For example, they and to RNs pursuing where the physician eventually diag- have challenged expert affidavits that BSN degrees. She has held mid-level noses a ruptured diverticulum. In this management and chief nurse executive have used statements such as, “Accord- positions in major healthcare systems, and scenario, there’s a chance that the PCP’s ing to information provided by the is currently a full-time LNC in a defense electronic documentation is inaccu- staff of the law firm, the patient com- firm that specializes in physician medical rate because of the closeness of time plained of left lower quadrant pain when malpractice cases. She is a member of the between the two visits. he visited Dr. X on February 18, 2015.” AALNC and a chapter Past President. She co-authored the 2014 medical literature The second scenario has the same set The defense attorneys that I work with module of AALNC’s online LNC Course. HAVE accepted expert affidavits that of circumstances, except that the patient She was a reviewer for the third edition visits the ER two weeks later instead are accompanied by an affidavit from the of Legal Nurse Consulting: Principles of the next day. In the second scenar- plaintiff.Affidavits, which are sworn and Practice. She can be contacted at io, it would be more difficult to allege statements, might be worded as, “When http://www.lnctips.com.

| 30 | THE JOURNAL OF LEGAL NURSE CONSULTING FEATURE

Roundtable Discussion on Electronic Health Records

Curated by Cheryl Gatti, BSN, RN, LNCC, CCRN-R

NCs are reviewing more Elec- paper/handwritten records were “I work for a defense firm, and I read tronic Health Records (EHRs). illegibility and difficulty identifying many records. Nearly all of our clients LTo create a dialogue regarding healthcare providers with handwrit- utilize EHR now and we have seen issues specific to our practice, we ten entries. Respondents cited large several brands of EHR from various posted five questions focused on the number of pages, repetitive informa- vendors. I HATE ALL OF THEM.” EHR on the AALNC website asking tion, and disjointed records as EHR members to identify problems they problems. Many thought that the “It is much more difficult to find have encountered. These are repre- paper record offered a more detailed information in some types of EMRs. sentative of the many thoughtful and description of the patient’s condition, Information is not as logically placed thought-provoking comments from but as one put it, EHR is “data-rich as in a paper record. Items that would 138 members who replied. and information-poor.” normally be on the same page are hidden throughout the record and are not easily JLNC: What has been your experience “Although every facility uses a different retrievable except by an expert on that reviewing EHR versus paper records? type of EHR, it’s usually easier to locate particular type of EHR.” information in electronic records versus Most of the respondents continue to paper records. However, EHRs generally “EHR are more costly to the client work with both paper and the EHR, don’t include full nursing notes. I have (because they) are generally not orga- with the obvious trend towards the found out a lot of valuable information nized to expedite review or prepare an EHR. The most common issues with in the handwritten nursing notes.” expert report, if necessary.”

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 31 | FEATURE

“I often see many pages of data that are specialty area documentation…EMR “The paging back-and-forth to look at detached from each other. For example, is key for reimbursement, but not to different parts of the record becomes dozens of pages of systolic BPs, followed truly document both subjective and ver cumbersome.” some inches later by the corresponding objective findings.” diastolics, and maybe later by pages of “Paper records are much easier in terms of means. Where are the vasoactive meds? “At first I thought it was really good (at establishing chronology. The print-out of electronic records are presented according The labs? The blood gases or ICPs? my hospital). Unfortunately, I have devel- to topic area, not chronologically, and are Physician and nursing notes? They’re oped bilateral nerve injuries in my arms much more time-consuming to review.” somewhere in that pile (maybe). How do because of all the keyboarding.” I look at this mess to see a patient’s con- “System glitches. Documentation is dition evolve over time? I do, but it takes “In simple terms? Electronic docu- unclear when handoff took place in ED a long time. This costs the client money.” mentation sucks.” harboring while waiting for a bed. ER JLNC: What have you found to be physician documents handoff to hospi- “EHR is clear and concise when it relates to talist, while nursing is still documenting the most difficult aspect of reviewing orders. However, abstracting data for meet- in ED EHR.” ing regulation requirements can be difficult.” the EHR? “…One day’s nurses’ notes may be “Very frustrating. The order in which “All the systems have different nuances: 100 pages.” the records come does not make much for example, Meditech labels a report sense…I have also located the same one thing, but it’s called something else in “The most difficult aspect would be the sheer thing (say, I & O) done in two different EPIC or Cerner.” “There are too many volume. The information was repetitive, but sections, not sure why. Some sections vendors resulting in a variety of formats. that needed to be confirmed as well as infor- come in chronological order, others are You have to know the way the EHR is mation that was pertinent to the allegations was scattered…There seem to be very little in reverse order.” organized from each provider before you opportunity for a free narrative, so (finding can review content.” “Actually easier to review EHR. I can and reading) multiple brief comments made store it on a computer, find and print what “With CPOE (computerized physician it even more time consuming to create that I want, and reduce paper load.” order entry), some doctors document clear clinical picture.” “Some positive, more negative. On the on incorrect sections. For example, “Progress notes are often repetitive, positive side, it’s easier to identify the they’ll use ‘Other Physician Note’ to repeating the same information in each healthcare providers, particularly the nurs- document the patient’s H&P, Progress day’s note. It can be very difficult to dis- es, who were involved in the patient’s care.” Note, Discharge Summary, etc.” cern new information.” “Pages & pages of repetitive information making a change in the norm difficult to "Copy-and-paste results in such inaccurate find, sort of like needle in a haystack.” documentation. This feature has come “Elements of a previous visit may back to haunt healthcare providers when be brought forward but not actual- ly reviewed by the provider. Billing records have been reviewed following the a higher level of service based on documentation (instead of medical patient’s discharge.” necessity and the chief complaint) can be a problem.” “With scanned documents, security is “It varies significantly between systems. “I sometimes refer to them as “exploded” an issue because online reading within a Some are fairly easy to navigate. Others records, since what happened to the patient secure server is still relatively slow — I are a virtual nightmare (no pun intended) is scattered widely in different categories.” end up downloading the documents in to try to find information. order to review them quickly and to enable “Having to look at one page for one thing certain features such as magnification and “Enormous paper dump; mostly not and another for another thing, and sepa- document orientation settings. Then I important to case, unless it’s ED or rate days being on separate pages.” have to have encryption software to protect

| 32 | THE JOURNAL OF LEGAL NURSE CONSULTING PHI under HIPAA, which is a good idea anyway for other reasons, but this makes it even more important.” JLNC: What do you think about CPF (the copy-and paste feature)? “The Joint Commission has received reports to the Sentinel Events database noting documentation errors and other problems with the integrity of the clinical record. Several sentinel events leading to patient harm reported the CPF as the specific root cause.” (TJC, 2015). “CPF is MOST problematic in that it is not only very popular (therefore fre- quently used) but that it results in such inaccurate documentation. This feature has come back to haunt healthcare pro- viders when records have been reviewed following the patient’s discharge.” the error?’ with the implication that the “The printed version tends to group things “Duplication of information…often it MD is not reading what he is signing.” together to make it look more like a summa- appears information has been cut and ry. A record can be printed out a number “My primary care provides access to my pasted multiple times to save time and it of ways from any system. Some reports are records in a patient portal. When I noticed may be very difficult to determine what hard to navigate, and others are easy. It errors about a surgery I had, I asked them to is new information, particularly with really depends on the system formatting.” correct it to the right procedure. They told me office visits.” they couldn’t do that because that procedure “I don’t think any of the programmers knew “It’s clear that end-users are using copy/ wasn’t a choice in their system. So there it that a hard copy would ever be necessary. paste functionality during their docu- stays, and there’s nothing I can do about it Therefore, there is NO resemblance between mentation.” “Canned” or cut and pasted because there isn’t a free-text option either.” the screen version and the hard copy. And for the LNC, viewing hard copies of multiple statements overused and fail to reflect pro- JLNC: How does the screen software programs is even more problematic.” gressive changes in a patient’s health status.” version of the EHR differ from “Providers’ BAD practice of cutting/ the printed version? “If you could actually log into the EHR it would show you how practitioners are copying and pasting, and then not “I understand from our nurse experts deciding their answers in drop downs tailoring what they’ve pasted to the that there is a big difference in what etc. (This would give you) good insight.” individual patient.” they work with on a daily basis and the “Physicians and mid-levels should not be final printed version we show them for “The clinician has absolutely no idea how allowed to copy and paste from another depo and trial prep.” their documentation prints out and in some cases, are very surprised in deposi- physician’s H&P or progress note unless “Totally different. Live, you can pull up tion prep that some the ‘boxes’ that they are they designate that note as originating what you need. Hard copy EHR are all checking are printing out the way they are.” from that particular provider.” together — with all of the duplicates, “It allows incorrect information to be and not by section (MD orders, I&O, “Oh my gosh - let me count the ways! entered in a patient’s history or current Progress notes, etc.) order.” The screen version is a bunch of check- lists - boxes, boxes, and more boxes. The problems, and that incorrect information “I use Meditech at my clinical job. A continues to be pasted into multiple printed Meditech record looks nothing EHR is the story of what was checked dates of service in the future. That incor- like the screens we use to document.” and what was filled into those boxes… rect information is in fact damaging to Did the patient get the drug the physician our case, and the question we always hear “The printout does not represent the prescribed? Look in one place. What is in cases is ‘Why didn’t the doctor correct screen version — period.” the patient’s output for the last few hours?

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 33 | “YES!!! Had a 6 week old where the EHR documented ‘nonsuicidal, nonhomicidal.’ The MD had a hard time answering that question in deposition.” “Yes, in an ortho case. All of the times that the tourniquet was applied, inflated & deflated printed as 0000, and there were clearly recog- nizable circulatory complications post-op.” “Yes. Nurses repeatedly documented that an individual had an NG (nasogastric) tube and he never did. The first nurse who assessed the individual marked it as present, patent, etc. and every nurse after- wards marked the same information.” “Yes. I had one where the vital signs were Look in another place. Is the patient’s pain inputting the data. Nevertheless, just like taken directly every five minutes from the controlled? Look in another place. It’s like paper chart, there is need to be mindful of cardiac monitor and these were preserved finding a needle in a haystack. And the what and how data are captured.” in the record. However, when the vital sign haystack is getting bigger and bigger.” pages were printed out, there were numerous “Not errors as much as metadata uncov- inconsistencies between these and vital signs “The EMR often omits free-standing ering late entries that were not apparent taken and entered by the nurses. It allowed documentation, like EKG printouts or from the produced record.” opposing counsel to confuse the nurse expert.” DEXA scans done in a different facility or department; I only find out about “No, although there have certainly “Yes. There is a feature in most EHRs that these because I look at billing. Here’s a been instances where I thought that allows one provider to ‘accept’ a previous bill for an MRI! Where’s the report?” should be the case.” “No, but that is assessment or observation. It is not unusu- serious and concerning.” al for one nurse/provider to accept status “I have met many nurses who have no idea of a patient when the LNC knows from how to read the electronic record. The com- “No, but I have been involved in a few cas- other notes that the NG tube has fallen ment is usually, ‘I have no idea what I am es where the records are not complete and out, the IV is infiltrated, or the patient has looking at, the chart doesn’t look like that.’” trying to get them is like pulling teeth. For gone down the drain in the interim period. example handwritten records not placed It makes the provider look like he/she is “When involved with nurses & risk with EMRs and any records that occur lying or is an idiot in deposition.” management, I encourage them to ask IT pre- or post-admit but related to admis- or RM to print a record from their unit so sion (ambulance, ED, and transfer, etc.).” JLNC: If you are clinically active, do they can see what they look like. Defendant you think the EHR hinders or facili- medical professionals who don’t recognize “Yes! ‘Accepting defaults’ got us a million tates good clinical practice? a printed EHR with their electronic signa- dollar + settlement.” tures all over it? Should not happen.” Responses were split almost evenly, with “Yes. A physician blamed Cerner (the a few more respondents believing that JLNC: Have you been involved in a EHR system) that a future lab order was the EHR facilitated good practice. Many case where EHR system errors were ‘lost’ in the system so it didn’t get done, thought that there are features that both a factor? and then the missed lab caused a delay in hinder and facilitate good practice. cancer diagnosis. There is government reg- Most LNCs who responded have “It has helped. A good system pro- ulation that basically protects the computer not been involved in an EHR system vides for checks and balances that software companies from being directly error case. It’s often difficult for the help you complete the appropriate LNC to know if there is system error liable…Doctor’s defense was that it was steps of documentation.” or user error. the computer’s fault. Research showed many docs do not adhere to mandatory “EHR has decreased errors, provided “I think the integrity of the EHR is as accu- education and that hospitals don’t punish safeguards and eliminated legibility rate as when it is put in, or (as) the person docs who do not comply.” issues. Date stamping and individual

| 34 | THE JOURNAL OF LEGAL NURSE CONSULTING password-protected login minimize “In the most recent Long Term Care constitutes normal vs. abnormal are the fraud and prevent tampering.” Home I have worked in, we are 95% laboratory data parameters. The point electronic records. As a manager, I find is that if nurses are not using the appro- “It can facilitate good clinical practice, as this makes my job easier when I am priate physical assessment descriptors to long as management takes advantage of following up on issues, auditing, etc.” describe their patient’s condition (as they things like bedside documentation and “The EHR facilitated good practice in should do), it leaves the nurse unprotect- chart auditing. Of course, it depends on the the physician office, especially when ed if the facility definitions for normal/ system. Some are better for certain areas of answering patient phone calls — the abnormal do not exist. Why then does the hospital. Unfortunately, many hospitals entire record was easily accessible.” hospital software use these terms so try to take the ‘one size fits all’ approach.” freely and in some cases set the nurse up “The Allscripts EMR that I’m familiar for possible future litigation?” “EHR facilitated good nursing practice with seems mostly intuitive, but there are as there’s an opportunity to be able to too many places to put additional notes “Definitely hindered. It is problematic in document completely IF one has developed that often get missed.” that there are so many shortcuts and so SMART (specific, measurable, achievable, many “clicks” that the end result is very realistic, time-oriented) phrases that are “I was hospitalized as a surgical patient poor communication of the care rendered individually focused on each patient.” recently (at a hospital I work at!)--and the and of the accurate condition of the whole was reduced to a patient. The Ebola experience in Dallas is “I work in a procedural area so I do not bunch of checkboxes. The nurses’ goal was a perfect example of healthcare providers enter much data into the system…I do to get through the extensive Epic EHR NOT being able to find or NOT taking appreciate that the physicians input their screens, and what a mess it was when I the time to find important documentation.” own orders — I think this will reduce was discharged. For example, there was “Most of the time I feel like a data entry the number of errors in treatment, one medication that my doctor asked me clerk. A majority of our documentation because we can actually read the orders.” to not take for a week (fish oil) — it has is meant to satisfy CMS requirements significant anticoagulant properties. Yet “The EHR Best Practice Alerts are helpful in order to drive reimbursement.” reminders to physicians and nurses not just my Epic-driven discharge instructions told for Core Measures but because it is best for me I could take it right away. If I wasn’t a “Completely has pulled the physician/ the patient.” nurse and knew to ask my doc about it, I practitioner and nurse from the bedside.” would have gone home and taken it.” “Can be useful as a reminder to complete “Hindered!!! We are focusing more “Yes, I definitely believe that the EHR and more time appeasing the computer tasks or to complete specific assessments has limited the reflection of good clinical instead of taking care of people! Mean- according to dx. Cleaner handoff as long practice. There are too many boxes that ingful use has caused nurses to focus on as all assessments were completed. Has use the words ‘normal’ and ‘abnormal.’ Yet charting at the expense of patient care.” helped to keep pace with quality reporting definitive facility policies and procedures by eliminating re-entry.” “No, I believe that EHR’s hinder good and nursing standards of practice do not clinical practice. Reason (and you hear “I retired from the VA. Our templates provide clear definitions on how when this over and over among RNs): It takes the use of these terms are acceptable (if provided the nurses with many drop too much time and puts focus on the ever) to use as part of the nurse’s notes. down choices for each category. This records and not the patients.” ensured that we captured standard items/ In many hospital facilities the only clear issues/guidelines.” P&P’s that provide definitions of what “I think the EHR is now geared toward insurance reimbursement and JCAHO re-certification.” “I think that it hinders good practice "I believe that EHRs hinder good clinical because it discourages free text.” practice. Reason (and you hear this over “I am not clinically active but I did teach clinical with BSN students. I find the and over among RNs): It takes too much documentation is poor. The staff check off time and puts focus on the records and entries but fail to write in details, such as pulses (quality, presence) prior to a leg not the patients." being amputated.”

VOLUME 26 | ISSUE 12 | SUMMER 2015 | 35 | HIPAA requires this. But there isn’t “Ask counsel to request the records by section clear law in every state on whether and then by date — all MAR together, all hospitals have to produce metadata to attorneys.” MD orders together, all operative records “Request an audit trail when records are together, etc. This is HUGE!” requested. The audit trail should provide when entries were made and by whom.” Many thanks to all who took the time JLNC: Do you have tools/tips you “I have finally surrendered to just to share your experiences and opinions. have found helpful in navigating and placing them in the order in which they We will continue the dialogue on other organizing the EHR? come and dealing with it as it just saves issues pertinent to our practice. Thank time and energy as well as my mental you to Julianne Clifton at AALNC for “I am frustrated with the process and I status. Just writing this out makes me compiling the data. have spoken to attorneys and paralegals feel better to get it off my chest, so who are as frustrated. The attorney looks thanks for asking.” REFERENCES to me with the expectation that I can Bowman, S. (2013). Impact of Electronic Health read these records and extract needed “If the original EHR is page-numbered, Record Systems on Information Integrity: information, but it is sometimes a monu- I do not rearrange pages — eventual- Quality and Safety Implications. Perspectives mental task to extract the information.” ly I seem to figure out the method to in Health Information Management. Retrieved that order!” from http://www.ncbi.nlm.nih.gov/pmc/arti- “I ask for a printed copy along with the cles/PMC3797550/ EHR on disk.” “You need to be VERY fluent in the soft- The Joint Commission (2015). Preventing copy- ware that scans and extracts pages, then and-paste errors in EHRs. Quick Safety. (10). “I find it much more time-efficient to review resorts them.“ records in print vs. on the computer. It’s much Retrieved from http://www.jointcommission. quicker to leaf through & compare side-by- “I am a huge fan of Adobe Acrobat Pro org/assets/1/23/Quick_Safety_Issue_10.pdf 4 side paper records than to scroll through and do everything electronically. I start by records on the computer & have to move bookmarking the records and then I orga- back & forth between computer screens.” nize the bookmarks and then the pages…I Cheryl is one of the don’t organize every set of records exactly founding partners of Lark “I just finished reviewing over 13,000 alike, but try to make them user-friendly & Gatti Medical Legal Consultants. Her clinical pages on the computer with no index of to the attorney based on the critical issues.” sections of the record, DOS, etc. Sadly, practice has included staff what I needed to know was limited to “I have found I need to save the PDF on and managerial positions in very few pages of that record, but I had a USB drive or my desktop so I can place medical surgical and critical care units. to scroll through the whole thing to locate Bookmarks on pages, which are import- She holds an alumna status critical care certification from AACN in addition to her those pages. So much irrelevant (to this ant for me to go back to in my analysis. LNC certification from AALNC.After case) information to scroll through! VERY After I am finished with the file, I do retiring from clinical practice in 2004, time-consuming with little to show for it!” delete these copies.” Cheryl's focus has been case review and “Ask counsel to request the records by “Learn a little bit about the system if development for Lark & Gatti. Cheryl is section and then by date — all MAR you are not familiar with it. Some sys- past president and one of the founding members of the New Jersey chapter of together, all MD orders together, all opera- tems will vary little between hospitals, AALNC. In addition to lecturing on tive records together, etc. This is HUGE!” because they are sold to facilities almost various clinical and professional topics, entirely built out. Others are custom Cheryl has been a reviewer for the “I don’t organize electronic medical built for and by the hospital. These are records unless I print them out and they’re American Journal of Critical Care, and the toughest ones to navigate.” published in Critical Care Quarterly. She unnumbered. If the pages are numbered also provided editorial review for The and printed, I keep them in that order as “It’s important to get metadata — the Manual of by that becomes my ‘Bates stamp.’ It’s too dif- tracking of changes that were made to Swearingen & Keen. Cheryl was one of the ficult to try to organize EHR when they’re the EHR. The EHR is virtual and most co-authors of the chapter on personal injury in digital format (such as PDF) so I use a facilities have a system for capturing the in the third edition of AALNC’s Legal Nurse lot of bookmarks.” updates and changes that were made. Consulting Principles and Practice.

| 36 | THE JOURNAL OF LEGAL NURSE CONSULTING THE JOURNAL OF egal Nurse Consulting

Looking Ahead…

XXVI.3, September 2015 — Expert Witnesses XXVI.4, December 2015 — ACA and LNC XXVII.1, March 2016 — Research in LNC XXVII.2, June 2016 — LNC Written Work Products XXVII.3, September 2016 — Infection XXVII.4, December 2016 — Forensics in LNC