Electronic Medical Record Metadata: Uses and Liability

McLean, Thomas R.; Burton, Lori; Haller, Chris C.; McLean, Patrick B.

doi:10.1016/j.jamcollsurg.2007.09.018

Cited by 15 publications

(14 citation statements)

References 6 publications

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“…19 Sophisticated computer-based auditing procedures, 20 as opposed to paper-based record sign-out logs, can identify individuals who review, or fail to review, key information in the EHR. 21 Take the scenario in which an abnormal finding is documented in the EHR and subsequently reviewed by multiple clinicians but never addressed. Although in paper records it is not always easy to tell who accessed that information, an EHR audit log easily reveals evidence of this lapse.…”

Section: Legal Dilemmasmentioning

confidence: 99%

Legal, Ethical, and Financial Dilemmas in Electronic Health Record Adoption and Use

Sittig

Singh

2011

Pediatrics

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Electronic health records (EHRs) facilitate several innovations capable of reforming health care. Despite their promise, many currently unanswered legal, ethical, and financial questions threaten the widespread adoption and use of EHRs. Key legal dilemmas that must be addressed in the near-term pertain to the extent of clinicians' responsibilities for reviewing the entire computer-accessible clinical synopsis from multiple clinicians and institutions, the liabilities posed by overriding clinical decision support warnings and alerts, and mechanisms for clinicians to publically report potential EHR safety issues. Ethical dilemmas that need additional discussion relate to opt-out provisions that exclude patients from electronic record storage, sale of deidentified patient data by EHR vendors, adolescent control of access to their data, and use of electronic data repositories to redesign the nation's health care delivery and payment mechanisms on the basis of statistical analyses. Finally, one overwhelming financial question is who should pay for EHR implementation because most users and current owners of these systems will not receive the majority of benefits. The authors recommend that key stakeholders begin discussing these issues in a national forum. These actions can help identify and prioritize solutions to the key legal, ethical, and financial dilemmas discussed, so that widespread, safe, effective, interoperable EHRs can help transform health care.

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Section: Legal Dilemmasmentioning

confidence: 99%

Legal, Ethical, and Financial Dilemmas in Electronic Health Record Adoption and Use

Sittig

Singh

2011

Pediatrics

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“…Electronic time stamps authenticate the time a provider creates an entry in a patient's record. After a provider completes an entry for an emergency intervention, going back to add a late entry can be considered in court to be falsification of records 22 . Another theoretic liability issue relates to the concept of comprehensive life course EHRs and the realistic limits of provider time.…”

Section: The Vision Of Meaningful Use and Perinatal Safetymentioning

confidence: 99%

“…After a provider completes an entry for an emergency intervention, going back to add a late entry can be considered in court to be falsification of records. 22 Another theoretic liability issue relates to the concept of comprehensive life course EHRs and the realistic limits of provider time. The comprehensive life course EHR will add volumes to the existent patient record, one of the theoretic mechanisms of improving continuity of care.…”

Section: Clinical Decision Support Systemmentioning

confidence: 99%

Electronic Health Records and Perinatal Quality: A Call to Midwives

Jolles¹,

Brown²,

King³

2012

J Midwife Womens Health

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“…Yet, as we move into the world of high-tech robotic medicine, few providers are aware of liability associated with metadata evidence. Commonly defined as 'data about data', metadata are automatically generated by virtually all computer programs [12]. The importance of metadata is that it creates an audit trail of the computer's use.…”

Section: Audit Trailsmentioning

confidence: 99%