The following is taken from a recent comment thread on my April 2008 post, "Clinical Plagiarism": Calling EMR copy/paste what it is that Reed Gelzer, MD, MPH, CDCC was kind enough to contribute to. I have only edited to explain acronyms & link directly to cited resources. Thank you very much, Dr. Gelzer, for these resources and informative insights that are not often part of the EMR decision, implementation and maintenance discussion. ~N.S. Dettmar
Here is a link to the public section of the American Health Information Management Association (AHIMA) website:
I'd recommend readers start with this paper from late 2005, the 14th on the list of documents at the link above.
Update: Maintaining a Legally Sound Health Record--Paper and Electronic
The electronic medical record (EMR) industry has been remarkably resilient to taking up basic documentation integrity functions, in large part because that is not something demanded by the buyers and users of these systems.
Eventually the accumulated weight of problematic and untrustworthy documentation will spill over into legal cases. Hopefully then the buyers and users of these systems will require better designed systems.
In the meantime, my associate and I have published a screening tool for evaluating electronic health records (EHRs) that we gave to AHIMA to publish as an article.
Gelzer, Reed D., Trites, Patricia, "Using Test Vignettes to Assess EHR Capabilities", in Journal of AHIMA, 5/2/06. We have published a more extensive testing methodology in book form, also thru AHIMA.
We find that many practices with EHRs do not know the risks these systems pose to them and so created these testing tools for an objective, reproducible evaluation of systems in place, or systems under consideration for purchase.
Copy functions in EHRs are actually just a subset of the problem of authorship accuracy. Since payment for services is driven by who actually provided the service, there are substantial financial incentives to use EHR capabilities to misrepresent who did what. Patricia A. Trites, of Healthcare Compliance Resources, often notes that EMR advertising especially highlights higher reimbursement as the main attraction of an EMR. Another auditing professional, Rebecca Busch of Medical Business Associates, notes that EMRs are simply too tempting to those she terms, "the ethically challenged".
My concern is that the majority of doctors, nurses, physician assistants (PAs) and other hardworking professionals will be doing things exactly as they should, but their EMR will betray them if ever challenged in a legal setting. For example, EMRs can dutifully record that documentation has been altered but not retain the original version, making it impossible for a doctor to prove that the alteration was not done for improper reasons.
I hope you have success in conveying to others the need for thorough due diligence in evaluating how a system actually works, to make sure it meets the basic requirements for valid, accurate, and trustworthy medical and business records.
Advocates for Documentation Integrity and Compliance
3 hours ago