Description
Medical & Legal Aspects of the Electronic Health Record
Presented by: The Florida Professional Liability Self-Insurance Programs:
Disclosure Statement: Randall C. Jenkins, Esq., Beth W. Munz, Esq., CPHRM, Stephanie Gann, BS, and Ryan Copenhaver have disclosed that they have no relevant financial relationships. No one else in a position to control content has any financial relationships to disclose.
Requirements for Successful Completion: This CME activity consists of an educational component (slides, audio/online lecture) which is followed by an online post-test. Certificates are awarded upon successful completion (80% proficiency) of the post-test. In order to receive credit, participants must view the presentation in its entirety.
Release Date: 07/01/2022
Expiration Date: 12/31/2024
Target Audience: Primary Care Physicians, Specialty Physicians, Physician Assistants, Nurses, and Residents.
Learning Objectives: As a result of the participation in this activity, participants should be able to:
1. Describe the financial incentive program under the HITECH ACT.
2. Relate the uses and users of the clinical record; the difference between an EMR and EHR; and what constitutes a legal health record.
3. Avoid or minimize risk factors by applying professional recognized EHR, documentation, and security recommendations.
CME Advisory Committee Disclosure: Conflict of interest information for the CME Advisory Committee members can be found on the following website: https://cme.ufl.edu/disclosure/. All relevant financial relationships have been mitigated.
Accreditation: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Credit: The University of Florida College of Medicine designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Contact: If you have any questions please feel free to contact SIPHELP at (352) 273-7006 or at SIPHELP@ad.ufl.edu.
Bibliographic Sources:
1. Silow-Carroll, Sharon; Edwards, Jennifer N. and Rodin, Diana: Using Electronic Health Records to Improve Quality and Efficiency: The Experiences of Leading Hospitals; The Commonwealth Fund Publication, July 2012 www.commonwealthfund.org
2. Amatayakul, Margret; Work, Mitch: “Best Practices in Electronic Health Records”; The American Health Information Management Association (AHIMA)
3. Keris, Matthew P.: “A View From The Trenches: Discovery Issues With Electronic Medical Records”; Risk Rx, The University of Florida Health Science Center Self-Insurance Program Publication, Volume 8, No.1 January-March 2011 http://www.sip.ufl.edu/riskrx.php
4. AAMC Compliance Officer’s Forum “Electronic Health Records in Academic Medical Centers”; Compliance Advisory 2/Appropriate Documentation in and EHR: Use of Information That Is Not Generated During the Encounter for Which the Claim is Submitted: Copying/Importing/Scripts/Templates; Association of American Medical Colleges, July 11, 2011
5. Dimick, Chris; “Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk”: AHIMA http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1
6. Hoffman, Jock, CRICO; “Hits and Misses” https://www.rmf.harvard.edu/Clinician-resources/Article/2008/SPS-HITS-and-Misses
7. Mangalmurti, Sandeep; Murtagh, Lindsey and Mello, Mechelle: “Medical Malpractice Liability in the Age of Electronic Health Records”; The New England Journal of Medicine November 2010
8. Ash, Joan; Berg, Marc and Coiera, Enrico: “Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors”; Journal of American Medical Information Association 11: 104-112 doi: 10.1197/jamia.M1471; http://jamia.bmj.com/content.11/2/104.full.html
9. Kern, Steven: “Hidden Malpractice Dangers in EMRs; New England Journal Medicine, December 3, 2010 http://medscape.com/viewatricle/589724
10. Richman, Donnaline: “Legal Pitfalls of Electronic Medical Records”; Dateline, A Newsletter for MLMIC www.mlmic.com
11. Young, Roxanne; “Copy-and-Paste”; American Medical Association http://jama.jamanetwork.com May 24, 2006
12. Dolan, Gina and LaSalle, Lori: “Pitfalls of Documentation in the Age of EHR”; The Health Law Partners
13. Sitting, Dean and Singh, Hardeep: “A fed-flag-based approach to risk management of HER-related safety concerns”; American Society For HealthCare Risk Management Volume 33, Number 2
14. Related Articles on Malpractice and Templates 2009-2012; http://www.praxisemr.com/templates_and malpractice_articles.html
15. “Feds eye crackdown on cut-and-paste EHR fraud”; Modern Healthcare December 10, 2013 http://www.modernhealthcare.com/article
16. Volpe, Anthony; “Liability Pitfalls of Electronic Medical Records”; Quality Matters, a Medical Group of Ohio Publication Spring 2011
17. Christie, J. S. “Chris: “Electronic Discovery For HealthCare Providers”; Bradley Arant Rose & White LLP www.bradleyarant.com
18. “Problem List Guidance in the EHR” AHIMA http://library.ahima.org
19. Dougherty, Michelle: “How Legal is You’re her?, Identifying Key Functions That Support a Legal Record”; Journal of AHIMA 79, no. 2 (February 2008): 24-30
20. Graham, Judith and Dizikes: “Baby’s death spotlights safety risks linked to computerized systems”; Chicago Tribune|June 27, 2011
21. Augelio, Tom: “Medication Error Proves Fatal”; CRICO www.rmf.harvard.edu/Clinician-Resources/Article/2011
22. Micheal Vigoda, MD, MBA, and David Lubarsky, MD, MBA,: “Failure to Recognize Loss of Incoming Data in an Anesthesia Record-Keeping System May Have Increased Medical Liability”; Anesth Analog 2006
23. Elisabeth Belmont, Esq; Samantha Chao, Alisa Chestler, Esq; Steven Fox, Esq,; Marilyn Lamar, Esq,; Kristen Rosati, Esq; Edward Shay, Esq; Dean Sitting, PhD, and August Valenti, MD: “Minimizing HER-related Serious Safety Events”: Part of AHLA’S Public Interest Series www.healthlawyers.org/publicinterest
24. “Medicare and Medicaid HER Incentive Program Basics”: www.cms.gov/Regulations-and-Guidance/Legislation
25. AHIMA Workgroup on Electronic Health Records Management: “The Strategic Importance of Electronic Health Records Management- Appendix A: Issues in Electronic Health Records; Management”: Journal of AHIMA 75, #9 (October 2004)
26. “Electronic health record”; Widipedia, the free encyclopedia http://en.wikipedia.org/wiki/Electronic_health_record
27. Menachemi, Nir and Collum, Taleah: “Benefits and drawbacks of electronic health record systems”; Risk Management and Healthcare Policy, published online May 11, 2011, http://www.ncbi.nlm.nih.gov/pmc/articles.PMC3270933
28. AHIMA, “EHRs as the Business and Legal Records of Healthcare Organizations (Updated). Appendix A: Issues in Electronic Health Record Management.” (Updated November 2010) http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1
29. “The Legal Electronic Health Record”: 2011 by the Healthcare Information and Management System Society (HIMSS), www.himss.org
30. AHIMA e-HIM Work Group on Defining the Legal Health Record: “The Legal Process and Electronic Health Records”; Journal of AHIMA 76, no. 9 (October 2005): 96A-D
31. AHIMA e-HIM Work Group on the Legal Health Record: “Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes”; Journal of AHIMA 76, no. 8 (September 2005): 64A-G
32. AHIMA e-HIM Work Group on Maintaining the Legal HER: “Update: Maintaining a Legally Sound Health Record-Paper and Electronic”; Journal of AHIMA 76, no. 10 (November-December 2005): 64A-L
33. Lawrence Shulman MD, Robert Miller MD, Edward Ambinder MD, Peter Paul Yu MD and John Cox DO MBA: “Principles of Safe Practice Using an Oncology HER System for Chemotherapy Ordering, Preparation and Administration, Part 2 of 2”; American Society of Clinical Oncology, Journal of Oncology Practice, Volume 4, Issue 5 2008
34. “The Problem List beyond Meaningful Use”; Journal of AHIMA, April 6, 2011; http://journal.ahima.org/2011/04/06/the-problem-list-beyond-meaningful-use/
35. Alicia Gallegos: “Medical charting errors can drive patient liability suits”: American Medical Association, http://ww.amednews.com/article/20130325/professional/130329979/5/
36. “Feds eye crackdown on cut-and-paste HER fraud”: Modern Healthcare, published December 10, 2013; http://www.modernhealthcare.com/article/20131210/NEWS/312109965/
37. “Do EHRs Increase Liability”: White Paper by: Larry Ozeran, MD and Mark R. Anderson, FHIMSS, CPHIMS; mra@acgroup.org or lozeran@clinicalinformatics.com
38. AHIMA’s Legal Medical Record Task Force: “Legal Documentation Standards: AHIMA’s Long-Term Care Health Information Practices & Documentation Guidelines” http://ahimaltcguidelines.pbworks.com/w/page/46501133
39. AHIMA: “Managing the Transition from Paper to EHRs” (Updated November 2010)”Data Integrity”: Wikipedia, the free encyclopedia; http://en.wikipedia.org/wiki/Data_integrity
Objectives
Learning Objectives:
As a result of the participation in this activity, participants should be able to:
1. Describe the financial incentive program under the IHTECH ACT.
2. Relate the uses and users of the clinical record, the difference between an EMR and EHR and what constitutes a legal health record
3. Describe potential patient care risks and exposures associated with the implementation and use of the EHR.
4. Avoid or minimize risk factors by applying professionally recognized EHR system, documentation and security recommendations.
Certificate
By completing/passing this course, you will attain the certificate CME Certificate-Medical Legal Aspects EHR
Learning Credits
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