Physicians: Best Practices for Entering Patient Data
In this episode, Healthcare Matters interviews ALL MD attorney Tad Devlin on best practices for entering patient data into an electronic medical record.
Devlin is a partner at KAUFMAN, DOLOWICH, VOLUCK. He practices law in California, focusing his practice in the areas of commercial and insurance litigation, ERISA/life, health and disability benefit disputes, profit sharing plan and employee stock plan disputes, real estate, financial services disputes, professional liability (lawyers, doctors, accountants, real estate, insurance agents, architects and engineers), disciplinary defense and white collar defense.
Devlin is a charter member of the Association of Liability Lawyers in Medical Defense (ALL MD), a nationwide organization that connects healthcare providers with attorneys who specialize in medical malpractice defense.
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Interview recorded June 17, 2015
Mike Matray: Hi, I’m Mike Matray and I’m the host of Healthcare Matters, where the legal and medical fields come together to discuss healthcare matters. Today’s guest is Tad Devlin. He’s partner at Kaufman Dolowich Voluck, Welcome to Healthcare Matter, Tad.
Tad Devlin: Thanks Mike, pleasure to be here with you.
Mike: Tad, how has the move from paper medical records to electronic medical records affected best practices for entering data into a patient’s chart and what guidance would you give physicians so that they are using best practices when entering data into their electronic medical records?
Tad: Yeah, it’s an interesting issue because we’re on the cusp of, well, maybe well into electronic records and portability, accessibility and even on our phones with mobile devices. So, gone are the days or almost extinct are the days of actual manual files. It has a lot of pros and cons and it has a lot of room for error, although the efficiencies in the technological advances, I think, in my opinion, outweigh the old way of doing things.
Best practices in the old days, if you well involved ensuring timely reporting, accurate record keeping for the medical files and, hopefully, contemporaneous reporting but there was typically a disconnect. If you’ve ever reviewed some doctor notes, you know it can be difficult, if not almost impossible, to read and understand what they’re writing. Also, you’ve got a challenge because if the doctor is no longer available to testify, to explain the records, it’s going to be difficult for anybody to do so.
Previously, we had a nice chain of custody with medical records, assuming folks were adhering to best practices. So, anybody who entered a log entry note or wrote up a medical file note, they put either their initials or their identifying information in there. So, reviewing insurance companies and/or professionals or legal practitioners could understand who was saying what and contact Dr. Jones or Dr. Smith and find out what they meant when they wrote some entry.
Now, we’ve got the electronic data entry and we have electronic databases, both internally and externally. It’s a bit of a challenge with the old guard, if you will, or the pre-text and the pre-phone at your fingertips generation and the new modern method of entering data and speaking. The same rules really apply but with more attention to electronic privacy and security and internal and external protection measures to avoid a hack, or a leak, or inaccuracy in reporting. So, I think that a blend between best practices from the old day, if you will, and the new day and proper training and kind of internal securities and safeguards, and doctors have continuing education requirements in technological advances and data entry and certainly on there, including, of course, under HIPPA privacy to ensure accuracy, privacy and security in the reporting. So, hopefully we’re having more, and I think we will, have a more efficient method of recordation and sharing and use. That being said, there are always issues out there with new technology and there are some here as well.