Accessing Available Information in Electronic Medical Records

September 25, 2013

Electronic medical records are a pervasive part of not only health care delivery, but of many legal matters. What most people may not realize is that the information that constitutes a “legal medical record” in most electronic medical record systems is far from a complete set of data regarding the delivery of a person’s health care. On September 20, Axley Brynelson was privileged to host a seminar put on by the principals of EMR Discovery regarding identifying what data exists and how to find it in electronic medical records. These topics and others were explored from a technical and legal standpoint.

While legal medical records satisfy the core mission of health care delivery and continuity of care, they omit much data that is valuable in other contexts. Knowing when medical records have been amended, who has been in the record at different times, what providers have a higher compliance level with institutional protocols than others and what providers actually see when they access a patient’s chart all may be important, but they are not facts revealed by the legal medical record. All this data and much more exist, but serves no purpose if it is not known and utilized. Knowing what exists and how to get to it technically and legally will become increasingly important.

This reality is particularly critical in a growing number of areas of the law. Medical malpractice and injury cases are obvious examples. Achievement of substantial compliance in Meaningful Use assessments is another. Sentinel Event and JCAHO compliance are another. Medical billing compliance and False Claims Act defense are another. The list goes on. The ability to understand both the technical capabilities of electronic medical record software and the legal ramifications of the information contained therein requires attorneys and consultants who understand these issues.

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For more information about "Accessing Available Information in Electronic Medical Records," contact Guy J. DuBeau at gdubeau@axley.com or 608.283.6704.