The Good, the Bad and the Ugly: A Deeper Look into Electronic Medical Records


Written by a Paralegal

Reprinted with permission from the August 24, 2009 issue of The Legal Intelligencer. © 2009 Incisive Media US Properties, LLC.  Further duplication without permission is prohibited. All rights reserved.

By including this article in TASA's Knowledge Center, TASA is not endorsing the products mentioned below.  The article's content is provided in an educational context and appears as part of a forum for legal professionals.

"Chicken scratch," "scribble scrabble," and "illegible" are all perfect words to describe the handwriting of some physicians. How can a document so vital be so indecipherable? It's hard to believe, but the days of having an unreadable script may be behind us. On a recent doctor visit, I was amazed to receive a script printed from the computer. Not only did I understand my diagnosis, but I could also read my prescription. More hospitals and doctor's offices are beginning the slow but steady process of becoming digital. The issue of electronic medical records (EMR) has been on the back burner for years. However, with President Obama's US Stimulus program, the issue of EMR has jumped to the front.

According to McKinsey Quarterly, the Obama administration will use EMR to cut health care costs and improve the quality of medical care.  In January 2009, ABC news reported on President Obama's goals concerning medical records. In President Obama's speech at George Mason University, in Fairfax, VA., he stated, "To improve the quality of our health care while lowering its cost, we will make the immediate investments necessary to ensure that, within five years, all of America's medical records are computerized." President Obama also commented, "This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests. But it just won't save billions of dollars and thousands of jobs; it will save lives by reducing the deadly but preventable medical errors that pervade our health care system."  It is evident that the Obama administration will be making every effort to ensure medical record technology is used by the health care field.

When it comes to law firms, medical records can be pivotal to winning your case. Whether your specialty is medical malpractice, insurance, workers compensation or commercial motor vehicle, you will find a need for obtaining medical records. The traditional way in Pennsylvania to secure records would be by drafting (by hand or computer) a subpoena duces tecum, certificate pre requisite, 20 Day Notice of Intent and Certification. While this method is still used today, most law firms hire outside vendor services to draft subpoenas and serve them to medical providers. Once the records are retrieved, they are duplicated on paper. As this slow process is taking place in firm number one, the firm next door hires a competent document retrieval service to prepare subpoenas, serve them and produce the records electronically. Once the documents are obtained, they can be categorized as progress notes, radiology reports, medications, orders, etc.

After the categorization process, they are scanned as a PDF or TIFF file. The complete files can be e-mailed directly to the attorney or paralegal over a secure site. The firm next door is ahead of the game because now opposing counsel will want copies of the voluminous records. With the click of a mouse, the paralegal can burn a CD of all medical records in a few minutes. As for the first firm, it would take at least 48 hours to gather all records, contact a copy service, copy the records at the firm's expense and then mail or deliver the documents (also at the firm's expense) to opposing counsel. When opposing counsel is out of state, this delays the process even more.

On a personal level, EMR can save you time and ease stress. Some hospitals and doctor's offices have converted to EMR.  It can be as easy as going to your doctor and signing up for access to your online medical records. Your doctor will have you complete an application and assign a password with login. In just a few moments, you will be able to access your medical records over a secure site. Say goodbye to calling your doctor to obtain medical documentation. You will now be able to view your past and present medical history.

The "good" part of EMR is the individual control over your records. An up-to-date and accurate account of your health history is always necessary. In some instances, EMR can also be shared with your registered pharmacy. Imagine being able to log in and get a copy of the script you misplaced. You no longer have to wait for your doctor to return a phone call. At your request, your information can be securely shared with your pharmacy or specialist. This technique is helpful to law firms because EMR gives you access to the plaintiff's doctor visits, prescriptions, hospital visits and admissions. This eliminates the review of useless records. If your firm is only interested in plaintiff's 2004 admissions, you can digitally search all 2004 activity. There is no fun in being the attorney or paralegal who receives 3000 pages of unorganized medical records from opposing counsel. The amount of time EMR saves your firm is immeasurable. Whether your client is an individual or insurance company, they will be able to see how cost-effective digital records can be.

As for the "bad and ugly" side to EMR, privacy is always an issue. Medical records should always be maintained by a secure site created by your medical facility. With extremely sensitive information like social security numbers, date of birth and addresses, EMR's should always be protected. Privacy concerns are important and should be discussed with your doctor or medical facility. The issue of patient data being reviewed by outside sources is the same as with paper. As always, only the doctors, nurses, and office medical staff should have access to your records. If you feel you can be exposed to privacy violations, contact your provider and do more research to find out more ways to protect yourself and your records.

It's impossible to ignore the direction EMR will go. For law firms, your vendor service should have a legal team who is experienced with subpoenas for your case region and different jurisdictions. Many insurance companies are being approached privately by vendor services who offer to put them on the front line of new technology. The same time and effort you put into researching your opposing counsel should be applied to technology. You want your clients to know that you not only investigate ways to properly defend their cases, but you can also save them money by being aware of new technology available to law firms. Providing your clients with every option shows them that you are consistently putting them first. A paperless hospital is a change that will affect us all. It reminds me of famous words by John F. Kennedy, "Change is the law of life. And those who look only to the past or present are certain to miss the future." For your next client, take a deeper look into electronic medical records. The future of your case may depend on it.

This article discusses issues of general interest and does not give any specific legal, medical, or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.  

This article may not be duplicated, altered, distributed, saved, incorporated into another document or website, or otherwise modified without the permission of Incisive Media US Properties, LLC.  

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