Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 2 , N U M B E R 7 – 8 , J U L Y – A U G U S T 2 0 1 5 ]
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R I S K M A N A G E M E N T
fatigue and did not even review the
alert, that time will be very, very
short. The plaintiff's attorney will get
that data in discovery, and will use
that time to argue the provider did
not even care enough to review
relevant alerts.
Information overload. It can be
very difficult to find the clinically
relevant information buried in all of
the information in the EHR.
Overreliance on what others
have put in the record. Providers
need to do their own clinical
assessment and not only rely on and
use what others have entered into
the record.
Input errors. Such errors are
very easy with drop down boxes,
default data, and pre-populated
fields.
So be very careful when
documenting. Check what your
documentation actually says, and
review the entry before finalizing it.
RISK MANAGEMENT STRATEGY
#3: ADDRESS THE USE OF
SHORTCUTS IN THE EHR.
Be careful with templates. Do not
allow copy and paste, or if you do
allow it, require author identification.
Do not allow prepopulated or auto-
populated fields. Add space for free-
form text and encourage the use of
free-form text to individualize the
record entry. Consider periodically
printing out a record to see the
completeness and consider whether
another provider could understand
what you did and why just from your
documentation.
REFERENCES
1. FAC § 64B8-9.003. Standards for
Adequacy of Medical Records.
2. Abelson R, Creswell J, Palmer G.
Medicare bills rise as records turn
electronic. New York Times.
September 21, 2012.
3. Letter from Obama Administration
on hospital billing. New York
Times. September 24, 2012.
http://www.nytimes.com/interactive
/2012/09/25/business/25medicare-
doc.html.
4. US Dept. of Health and Human
Services Office of Inspector
General. Not All Recommended
Fraud Safeguards Have Been
Implemented in Hospital EHR
Technology. December 9, 2013.
oig.hhs.gov/oei/reports/oei-01-11-
00570.asp.
5. US Dept. of Health and Human
Services Office of Inspector
General. CMS and Its Contractors
Have Adopted Few Program
Integrity Practices to Address
Vulnerabilities in EHRs. January
2014. oig.hhs.gov/oei/reports/oei-
01-11-00571.pdf.
6. US Dept. of Health and Human
Services Office of Inspector
General. Compendium of
Unimplemented Recommendations.
March 2015. oig.hhs.gov/reports-
and-publications/compendium.
7. Federation of State Medical Boards.
Report on the Committee on Ethics
and Professionalism – Framework
on Professionalism in the Adoption
and Uses of Electronic Health
Records. April 2014.
www.fsmb.org/Media/Default/PDF/
FSMB/Advocacy/ehr_framework_fi
nal_adopted.pdf.
8. North Carolina Medical Board.
Position Statement on Medical
Record Documentation.
http://www.ncmedboard.org/resour
ces-information/professional-
resources/laws-rules-position-
statements/position-
statements/medical_record_docum
entation.
9. US Dept. of Health and Human
Services. Case Examples and
Resolution Agreements.
www.hhs.gov/ocr/privacy/hipaa/enf
orcement/exampl.es/index.html.
10. Joint Commission. Safe use of
health information technology.
Sentinel Event Alert. 2005;54:1.
www.jointcommission.org/assets/1/
18/SEA_54.pdf.
11. ECRI Institute. Top 10 Patient
Safety Concerns for Healthcare
Organizations 2015.
https://www.ecri.org/Pages/Top-10-
Patient-Safety-Concerns.aspx.
12. Bowman v. St. Luke's Roosevelt
Hosp. Ctr., 2011 NY Slip Op
32738(U) (Sup. Ct.).
AUTHOR AFFILIATION
: Ms. Vanderpool is
Vice President, Professional Risk
Management Services, Inc. Arlington,
Virginia.
ADDRESS FOR CORRESPONDENCE
:
Donna Vanderpool, MBA, JD,
Vice President, Professional Risk
Management Services, Inc., 1401 Wilson
Blvd., Suite 700, Arlington, VA 22209; E-mail:
vanderpool@prms.com
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