Due diligence is key when it comes to EHRs and malpractice

It’s not what you say that matters — it’s what you do and how you use it.

[See also: Docs who used EHRs showed lower malpractice claims]

So goes the motto blanketing all professions and endeavors, from campaign trails on down to the compassionate acts of ideal citizenry, where the candidate meets an elderly woman and a passerby helps her across the street. In the healthcare technology world, this pay-it-forward mantra demands amplification; it must remain constant and pressing, it must take-it-forward. There is no time to fumble around for the correct change.

Instances of EHR transitions have a tendency to muddle such advancement, plateauing some practices and putting them at risk for fraud investigations and medical liability issues. The reins often get tossed and the practice inevitably loses itself where it could easily thrive.

[See also: At AHIMA, defining 'The Legal EHR']

“Most transitions to EHR lack adequate planning, analysis and design to preserve integrity of patient medical records, introduce contextual patient information, and ensure accuracy of EHR based documentation,” said Ronald Sterling, EHR consultant, Sterling Solutions Limited, during his MGMA session “Malpractice Discovery in the Age of EHR.”

“In many cases we are ceding any control — we are ceding decisions — to best practices that are promulgated by various vendors, we are giving up clinical control to techno geeks, and we are basically letting the system run our office and our organizations instead of the other way around.”

Naturally, the best way to get through any fraud or malpractice investigation is to avoid it by conducting thorough preliminary documentation and maintaining records from EHR implementation onward. But given the mass uncertainty perpetuated by shifting regulations and the variety of capabilities available within any EHR, it’s also equally natural for a practice to find itself in a bind.

“We are going to be introduced to all kinds of information that we’re capturing in the health electronic record that we don’t have to worry about in the paper world,” Sterling noted. “We also are subjecting ourselves to a possibility of inaccuracy in the medical record not because of what we do, but because of how we use the system.”

So what do these examinations demand of a practice? According to Sterling, it’s a little show-what-you-know mixed with some show-what-you-did.

“In a fraud or malpractice investigation you’re going to have to demonstrate that you did do due diligence in your selection process, that you did care and that you did check to make sure that you could accurately and fairly represent and document the services that were provided to patients in your electronic medical records,” he said.