Friday, January 7, 2011

Over-Automation of EMR Note Creation Encourages Missed Diagnosis and Incurs Medical-Legal Risk

Over the past several months I have read several online discussions and comment threads on the medical-legal issues raised by EMR, including an HIMSS brochure on the subject.  Most of these discussions miss what I consider to be most important legal weaknesses of an electronic medical record. I finally came across an online discussion that comes closer to covering what I consider to be the most important medical-legal issues.

When we were setting up our EMR about 6 years ago many of our docs came to me with the same request:  “I want to create a chart note with a single button click.”  Although that was obviously a bad idea, their desire for it was understandable, given our inexperience at that time.  Templates are widely recognized as an effective method of documenting care and complying with CPT coding requirements.


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