How supervising physicians can minimize medical liability risks connected with ehr use

How Supervising Physicians Can Minimize Medical Liability Risks Connected with EHR Use

The electronic health record can improve standards of care, allow providers to actively participate in a patient’s care plan and ease the medical record review process. Following some tips could help reduce liability risks associated with EHRs.

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The electronic health record can improve standards of care and allow providers across various health systems to actively participate in a patient’s care plan; it can also ease the medical record review process for medical and legal entities. However, just as any other good thing, it has its share of drawbacks and one of these shortcomings is the risk of medical liability it carries for clinicians.

Let us for instance, consider the case of supervising physicians who are required to provide training in EHR documentation for medical students. This is something very important from the point of view of patient care and communication among providers. So, what are the risks involved?  Inappropriate password use: With EHR implementation, medical students must be provided with a password to access and use the medical charts of patients. These passwords are typically created for a relatively brief period of use. Physicians must be cautious never to give their own password to a student for independent access or documentation. It is important that each person logs into the EHR and enters information using his/her own

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password. A second password could be assigned to students to use if they are working as medical scribes. This is because when acting as scribes, the students may not be providing care for the patient but just doing the documentation. When there is a second password to distinguish this duty, it will help differentiate the two types of entries. Healthcare entities must also comply with state, insurer and organizational requirements for medical scribes.  Inaccurate entries: To ensure liability protection, the medical record should be accurate. Teaching physicians are responsible for their own medical chart entries as well as reviewing the entries made by students. To avoid errors from becoming part of the medical chart, ensure that all these mistakes are corrected promptly. When medical students are documenting in the EHR, other risks include using templates that auto-populate fields that may not be used during the encounter; and copying and pasting information from an earlier encounter that may not accurately reflect the current status. The supervising

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physician must necessarily review the note and correct any mistakes that are noticed. If there are conflicting entries within the medical record, it can create doubt and potential liability risk.  Errors in medical billing: Supervising physicians must be careful to ensure that the services provided by a medical student are not billed. To bill for a particular encounter, the physician must be present and participate in providing the service. Strict documentation requirements exist for the supervising physician to demonstrate involvement in the patient encounter and justify a specific E & M medical code. If a supervising physician uses student documentation to support a bill, it could lead to claim denial and may even be considered fraudulent. This could invite fines.

Teaching or supervising physicians could expose themselves to considerable risk if they are not careful with their EHR use. To minimize liability risk, there are a few tips to consider.  Have clear-cut policies for student training, EHR access, and patient encounter documentation.

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 Be sure about regulations related to participation during a patient encounter.  Ensure compliance with all CMS regulations, payer requirements, and state and accreditation requirements.  Set clear expectations regarding maintaining the integrity of EHR documentation.  Make sure that all EHR users are educated on the importance of medical record integrity and have rigid rules against using another person’s password to log in to the system.  Review and correct student documentation promptly and give feedback to the student immediately.  Monitor compliance in all respects.

EHRs can be the provider’s best friend if used in the correct manner for medical data entry, medical record review, sharing information and so on. However, it is also easy to misuse it and end up with serious medical liability issues. Keeping in mind the above facts should minimize such liability risks and enable

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healthcare providers to make the best use of the electronic medical chart.

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