Just a decade ago, only 15 percent of doctor's offices kept electronic health records (EHR) on their patients. Following the passage of the Affordable Care Act, the requirements to use and implement electronic health records has made them a part of daily practice. Though electronic health records coordinate patient care and add another layer to patient safety, one unexpected aspect of the switch to electronic health records is an increase in patient complaints and claims. Documenting patient interactions, symptoms, narratives and advice in real time significantly diminishes the amount of face-to-face contact with the patient. It is a truism that patients are less likely to bring a medical negligence claim against a physician they like, and patients tend to like doctors that spend an adequate of time listening to their concerns and talking to them about their options. When the doctor is focused on a computer and not on the patient, the level of patient dissatisfaction with the relationship increases.
You will be well served to take the first part of your medical consult interacting with your patient, and only after they feel comfortable with your relationship should you begin to document the patient consult. It also helps for you to be aware that the patient may feel ignored during the process of documenting the visit; apologizing for the need to do so, and describing for the patient that you want to make sure to include all of their information in their record so that you can thoughtfully consider it will help avoid unnecessarily impairing your patient relationship.
You will have to practice finding a balance between establishing a relationship and documenting the visit. Don’t ignore the human interaction in an effort to be more efficient and to see more patients in your practice. The adverse impact on patient satisfaction is not worth the increased risk that a dissatisfied patient will seek legal relief, and that oversight will also lead to the possibility that you might not be able to obtain (or retain) that patient, or that an unhappy patient will take to social media to describe their experience and to give you a negative rating (on sites that rate experiences with physicians).
The second area of risk associated with EHR is the “smart text” developed for each specialty to facilitate data entry and speed up the time required to document the consult. Programmers develop default text and data to speed up the process of entering patient information. But the most commonly used phrases suggested by the program may not be accurate descriptions of the patient’s condition or concerns. If the suggested text is incorrect or inaccurate, the patient’s medical record will not correctly reflect your consult, and in the event that a legal claim is made, the faulty medical record will play an instrumental role in creating liability for you. Pay close attention to the default text entered into the patient record, because once you sign it you are verifying that it is accurate and correct. If you have to testify under oath that your records are incomplete, inaccurate or just plain wrong, your credibility will be irrevocably damaged and the fact finder (court or jury) will develop a very negative view of how careful you are in providing patient care, when the plaintiff has alleged that you acted negligently and injured them in providing their care.
Electronic health records also raise concerns about patient privacy issues. An aesthetic patient seeks a breast augmentation and liposuction. She demands that this surgery remain private and is not to be shared with anyone. No insurance is involved and therefore no fraud issues arise. However, in a health system that increasingly relies on electronic information to provide comprehensive care, these surgeries will be apparent to any medical provider that she consults and to their staff.
Of course, all subsequent providers have a strict obligation under HIPAA to protect this private information, but you should explain to your patient that her desire for privacy relies on all providers fulfilling their legal obligation to her, not on you limiting the information described in her medical record. If subsequent providers raise the surgeries and their possible impact on her future care, your patient should be prepared so that she is neither surprised nor upset when that occurs.