Electronic Health Record (EHR) & Electronic Medical Records (EMR) are often assumed to be the same because they are both digital version of a patient’s health record. However, there is a significant dissimilarity between the two and their influence on a lawsuit.
EMR
An Electronic Medical Record is a digital version of a patient’s chart. It contains all details “medical” such as diagnosis and treatment history. This digital record typically stays with the provider’s office and is not shared with any other practice. If a patient changes from one doctor or hospital to another, his or her EMR likely will not be transferred. Instead, the patient’s records might have to be printed, scanned, and e-mailed or mailed in order to be shared. Benefits of an EMR include:
- Monitoring and identifying which patient is due for treatments, therapy, or vaccines.
- Tracking internal performance metrics.
- Improving the care delivery model.
- Its digital nature allows easy storage & accessibility preventing errors, loss & tampering of sensitive information.
EHR:
An Electronic Health Record contains the patient’s records from multiple doctors or hospitals and provides a more ample, long-term view of a patient’s health. It consists of a patient’s demographics, test results, present illness conditions, clinical history, mental health data, current and present medications. Benefits of an EHR:
- Allows sharing of important health information nationwide (or worldwide) in a protected manner.
- Aids important decision-making processes in terms of a patient’s health.
- Acts as a repository for all test results such as lab tests, x-rays, radiology results, etc.
- Improves patient engagement by allowing patients to access and comprehend their health metrics.
How to use an EMR & EHR efficiently in a claim or lawsuit?
When compared to documented paper records, a digital patient Electronic Health Record or Electronic Medical Record is an additional information administration tool that helps attorneys efficiently organize, understand, and analyze a patient’s health information and data. EMR or EHR offers access to a patient’s medical history, diagnosis, medications, treatment history, and evidence-based tools to support clinical decisions and the standard of care, which is information that is necessary to proceed with an insurance claim or lawsuit. The information contained in the EMR or EHR may be relied upon, depending on the circumstances of the case, to prove liability, causation and/or damages. Also, there are times where an audit trail of the EMR or EHR themselves is evidence that can be utilized in a medical malpractice case, as it may show when information was viewed, added, or deleted, or modified, that may be the key to prevailing in a case.
Here are few issues attorneys and law firms should be mindful of while accessing EHR’s & EMR’s:
- Be aware of the shortcomings of an EHR & EMR: Most EHR’s & EMR’s have an “auto-fill” option that automatically fills up previously recorded information.
- Gaps in recorded information: Healthcare practitioners can continue to record information even when the EHR is down, thereby implying to the attorney that any gap in the documentation should have a reasonable explanation.
- Security: Attorneys should ensure that all health records retrieval processes are compliant with HIPAA standards and are protected against breaches by hackers.
- Computer Reset: Attorneys should ensure that all health records are backed up before resetting their computers or installing new software to avoid loss of data.
- The meta-data and data trace an Electronic Health Record leaves can be used in a medical malpractice case to prove liability.
AcroDocz provides medical records retrieval, review, and summary services for law firms and attorneys. Our team includes proficient retrievers and summary developers that are capable of simplifying data obtained from an EHR into an easy-to-understand medical summary or chronology report. To learn more about our services, please complete the form below.
