CHICAGO — Here at the Radiological Society of North America’s RSNA 2011 annual meeting, I had a flashback.
A presenter was going over how his large radiology group handles fuzzy or errant scans. It involved a multi-step rigmarole that included making anonymous the bad images so they would never be used in the course of a patient’s care, yet somehow making them accessible and identifiable from one picture archive database or another on the off chance a HIPAA audit trail were ever needed.
Frankly, I stopped thinking about the legal electronic health record (EHR) and started thinking about fantasy football about two-thirds of the way through his explanation. Otherwise I’d have repeated it back perfectly.
The important point is this: When, might one ask, would an audit trail involving a fuzzy chest X-ray ever be needed? When the lawyers ask for it, of course.
That makes sense, actually. Not like I’m a big sympathizer with lawyers, but anyone interested in investigating things and tries to re-create what actually happened after the fact (law enforcement, reporters, script writers, physicians sleuthing better care methods, anyone analyzing quality metrics to earn incentive payments…you get the picture) needs to see complete information.
When there’s a gap, there can be a smoking gun — it makes the investigator question the motives of the deletion. Why was this information “mysteriously” removed? There had to be a reason, right? It opens the door to conspiracy theorists.
The flashback happened when I realized that, in a session during October’s American Health Information Managers Association (AHIMA) annual meeting in Salt Lake City, a health information manager was explaining best practices for maintaining the most complete legal EHR — and was talking about the same thing.
What happens when a physician cuts and pastes the wrong information in an EHR — or, as is common, the record is updated to something more accurate after test results come in — and the audit log shows something was deleted? The lawyers come after the hospitals and say “A-ha! Smoking gun?”
To counter that syndrome, her hospital adopted the policy of keeping everything — even the wrong information — in the EHR to show what was deleted, by when, and by whom. But her EHR system cannot accommodate this, so hospital policy is to put it in what the vendor calls “draft mode.” The text doesn’t appear live on physicians’ screens and appears grayed out in the HIM manager’s view.
Both of these scenarios point to one thing. Vendors either aren’t with the times or don’t care about these realities of the clinical recordkeeping environment. It would be easy to blame the lawyers and the cockamamie times we live in where the world’s been turned upside down.
But the reality is, it’s not just lawyers who need complete medical records, complete with errant information. Electronic information systems — and their audit logs — will help health care understand how and when errors are made, through their capturing of the patient time line.
These two speakers at two very different health care conferences were charged with using the tools at hand to meet real-world needs. And they weren’t just the average health care provider, either — they were both in charge of very large patient bases at forward-thinking facilities. Since their software tools didn’t serve the real world, we get alternate databases and grayed-out “draft mode” for real-world patient records instead of a true legal EHR.
My life could hang in the balance some day and the ability for my physician to figure out the HIM manager’s workarounds could figure in to the outcome. Are you kidding me?
Sounds like a real opportunity for a new health IT vendor to take advantage of this disconnect, because current-day vendors have their heads in the sand over how complete medical records — called “the legal EHR” because some people like to make lawyers the bogeyman whenever they can — actually work.
In reality, you and I — the patient, that is, not the reporter — need complete information just as much as lawyers do. And from the looks of things, health care is not getting taken care of.