11. October 2016 09:16
The healthcare industry is already well aware of many of the larger-scale challenges of electronic medical records (EMRs), including issues related to cutting and pasting, not making timely updates when conditions change, and caregivers making late entries. Additionally, EMRs are typically implemented in modules, and hybrid records are still common in many settings. These many variables in the use of EMRs potentially pose a legal risk. The process of extracting records from EMR systems is no different.
Excelas has retrieved more than 600,000 pages of medical records from a variety of EMR systems and for a variety of projects and has observed some common trouble areas. Be aware of these six top issues when pulling electronic records.
- Internet headers/footers/menus printing out on the page – Healthcare providers typically expect that there will be no URLs or menu tabs on the printed record. Such elements are not a part of the medical record, but rather an artifact of the extraction process. Therefore, their presence on the printed record effectively changes the integrity of the record. What is shown is not a mirror-image of the original medical record. When pulled correctly, these elements will not be visible.
- Username appearing on the extracted record – Some EMR systems have record types that display the username of the person extracting the record on the printed page. To avoid the issue of a requestor questioning who has handled the patient’s record, procedures should be established and followed that prevent the username from appearing on the printed record.
- Records that say “No Data” – When pulling records from an EMR, users must ensure they are pulling the correct document types within the correct date range for the patient in question. For example, if a patient did not have physical therapy in March, forcing the EMR system to pull a March therapy log may result in a page that says “No Data.” Such a record might give a false impression that therapy was not tracked properly, when in fact there simply were no services provided that would result in the creation of a record entry.
- Wrong patient information – In some systems, there are record types in which the individual performing record extraction may choose to include “All Patients,” rather than just the patient in question. The result will be a record that shows personal health information (PHI) for all patients from that timeframe, rather than just a single patient. This is a common oversight, and the solution is performing quality review prior to releasing an electronic record to avoid an inadvertent release of PHI and possible HIPAA breach.
- Inconsistent record extraction methods – Especially when pulling multiple records for a single project, such as an audit or response to a government subpoena, it is important for the extraction team to pull every document and record according to a standard operating procedure with consistent rules and parameters. If one record set is produced differently than another, it may trigger suspicion that information is being withheld or not being tracked properly.
- Forgetting the hard-copy portion of the chart – Many facilities still maintain a hybrid medical record, with portions of the record contained in an EMR while some departments continue to document on a paper record, or possibly even in a separate system. It is important to examine the EMR to ensure all record types and relevant dates are included. Best practices for an organization will assure there is a matrix of medical record documents that details all systems containing patients’ clinical documentation, the dates EMR modules went live, and a department-by-department index of all clinical documentation they maintain.
There are many things to watch for and be aware of when extracting electronic medical records, and these are just a few examples. Not taking appropriate care when extracting records can lengthen the record production process (e.g. producing an incomplete chart, then needing to gather the missing records). Records extracted inconsistently may generate a new set of questions from the requestor; may add more time and more cost to the preparation of the case; or may give the impression that the company producing the records is disorganized, opening them up to further scrutiny. The key is to be consistent, detail-oriented, and vigilant about keeping extraneous information off of the printed page.
Need help extracting electronic records? Check out our Electronic Medical Record Retrieval!