How To Sign Michigan Banking Medical History

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time for our first panel and our first panel is going to be talking about electronic health records we have in the panel Jennifer Andrew from Plunkett and Clooney she's an attorney also attorney Dan Baer from care Russell as well as dr. Fabian fregoli from st. Joseph's Mercy Oakland well good morning I'm Daniel buyer I'm wicker Russell and we have a presentation for you and it's a little bit going to be a little tricky because I'm going to try to look behind me and go through my notes here okay first I would just point out that this area electronic medical records is a it's sort of a new frontier for all of us we're all kind of learning as we go and from our perspective I think we're all prepared here my colleagues to comment on and make comments about these a lot of these are going to be admittedly a anecdotal is this has come up in our respective practices so I would encourage any of you that have any questions or comments or even their own your own anecdotes to shout them out or if you have questions we'll do our best to respond to those because at least when I'm in your position a lot of the times when I go to these presentations I have these little these little terrorism's or tears so terrified thoughts in my head about a particular issue that I would appreciate some assistance or guidance on so I encourage you to do that and frankly I think maybe all of us here I think I speak for all three of us we we would have no problems with answering your questions or responding to them so the first slide here is a snippet from the Michigan lawyer's weekly that occurred probably about a year or so ago and the the phrase at the bottom which I'm not sure is totally legible and from the people in the back I'm sure it's not legible says the electronic records have opened a new realm of med mal liabilities so we had some ominous comments and one of them was from a well-known plaintiff's lawyer in town Brian McKeen who made a comment that these are now a danger in a world in the world was a safer place with handwritten charts and a lot of this I think is somewhat over overstated and overblown and the issue of patient safety being the component of medical care is a topic for another discussion at another time just just to insert day and for a moment obviously that dovetails into the reptile theory that many of us are probably familiar with that McKeen's trying to make the record issue now another issue in the reptile theory again to try and dummy down medicine and make it one of safety versus judgment so his quote there is that the advent of medical records has shifted the interface between the physician or as you know as we sometimes call them health care providers away from direct patient contact and shifting toward a keyboard or a menu and that this loss of interpersonal contact is feeds into this argument that electronical electronic medical records not being the panacea for improvement of care are now becoming a liability and in fact diminishing care which i think is we'll talk about it in a few slides down the road is really an issue of whether claims increase as opposed to care of being decreased and another plaintiff's attorney Chad Englehart noted that you know the the comment that keyboards are now as important as scalpels again comments about the the trend in some plaintiffs attorneys claims to make this one of the arguments and the reference to default settings and false information being putting it into chart and we can talk a little bit about copying and pasting now that that that's you know appropriate but the the issue is you see you now see these charts that are printed and they have multiple duplicative material that is not as focused on a particular encounter with the the patient as is what actually occurs you see this multitude of material so if I can just comment one of the things that we have physicians don't go to medical school and residency for the purpose of for a love of documentation I mean it's the fact is that we love patient care we love to take care of people the documentation is almost the afterthought but in in the in the world that we we live it becomes a very defensible document one that helps protect us as well in an environment that is you know some sometimes a little contentious when when outcomes aren't perfect right or there is a concern about the way the care is rendered but I think what has happened over time and I think with the new millennial generation coming in I don't think the keyboard is going to be the primary issue because there's so much keyboard in their lives and younger people today that that interface is less of a problem and it's actually appreciated and there's a comfort level as we see residents documenting not an issue it's the later generations those that have been in practice for a long time and when we implement an electronic health record whether in an office or in the hospital the lack the skill that's lacking is not the medical knowledge or the surgical skill or whatever it's the ability to type and and that is a critical skill because the the quality of that document that medical record is limited because of the information if I can't type and I struggle just putting in a username and password can you imagine typing a progress note or a consult it's just ridiculous and it's it's so time-consuming I'll spend most of my time with the documentation and very little time with the patient and now we have a flip and that's exactly what physicians don't want to do but it does create a problem and and the copy-paste feature as dan mentioned becomes a very convenient way to populate information and and I'll just leave it at that but that's that's the dovetail where we we see the rub I think it'll get better as time goes on as people are more comfortable with with using electronic devices like computers but anyway that's that's my comment just to add on to what dr. fregoli said with the copy paste I'm sure we all know what we're talking about but it's literally taking an entry from the day before and pasting it onto the next day or hour-by-hour included amongst my client base is a National extended care facility or nursing home and I see it a lot in that setting you need to be particularly cognizant of it with certain types of practice where the people are overworked the conditions don't change much from day to day they're being asked to track everything from how input/output bowel movements you know how much did you eat I mean it's a enormous amount of material and the tendency to want to copy and paste is there but you really need to counsel those clients or if you're in that health care industry to be very cognizant of not copying and pasting yes sir printing records I found that to be very problematic because it records and really intended to be printed one computer and I know it right now that's a requirement for legal pay but you know I found instances where the printed record is almost unheard of a lot of the time and and it seems like we're not allowed as mm II invited Oh at the PMC just to be able to come in and actually show it live and the way it was supposed to work example I have is a case in which that the problem with concern is associated with patient not moving power and so as things get added to the problem list when you printed out the existing problem with it applied to every batch encounter yep yeah it made it look like a condition to falsify that at a problem hospitals and how it was really not welcome to say you know that's a really excellent point and I think if there's you know the among the many things that were encountering and dealing with EMR and the litigation context is and what I like to call the old days you know you'd have a physical you have a physical chart okay and you have a form and the form would start like this and you start to write on it and then that form or that that progress note or that page and the chart would have this additional data put on it and what you would have copied for litigation purposes would be those those papers and if but we have now a circumstance that the printed material that we receive and we as defense counsel and we say give us you give us the chart get the chart what we get in paper on paper isn't what is being seen on the computer screen when the actual data that we've how we see by paper is given to us so it's not the same thing and we it's often the case that when I'm meeting with clients and they have them bring the charge and a of paper is brought and then I mother's by the way there's an additional computer screen that I can't really plant and it has this other information so you're you're kind of left with this sort of sense that you're not you're not on a solid ground you'd like to think you're on when you when you feel you have the entire record because there might be something floating out there and I guess the best comment I would have is just be aware of that and be prepared to ask questions of your clients or if you're a physician you know mention this to your attorney because many of us or most of us are not we don't deal with electronic records in our practice generally in the sense that we're inputting and inputting data and we have a mentality that whatever we have in our computer systems can be printed as it is on the computer so our mindset is not where yours is so I think that's at least being able to ask these questions so that the you know these concerns can be addressed and I'd like to pose this to the panel that Chad in this comment makes a comment about EMRs make it easier to detect an altered medical record and I thought that was an interesting comment I'd like to maybe get your insights on and I'm going to put you both on the spot a little bit to see how you might respond to Chad's comments in that regard all right I think he's accurate again in the old days I hate to say many of us probably remember the drive up to Lansing to meet with lieutenants b'keen and you'd take your records you know praying as he stuck them under the microscope and he could date us the ink that was done the pages the impressions would lift up and you'd sit there nervously waiting to see if he was going to say that your client had altered the records or when certain entries were made now we're routinely getting requests for metadata trails to show when things were inputted if someone went in after afterwards and added something or change something and that the author every time someone opens a chart your name is in there as to who opened the chart a lot of the HIPAA cases that I defend come in because it shows someone who should not have been in that portion of the record or even have access to the records opened the chart so I think he was absolutely on point well I know it's a segue into this I brought a little you know little what this is a paper anecdote so to speak and the issue of audit trails and one person's access the records and when they have ability to look at them and the issue of when items are are done is really becoming a almost routine request from plaintiffs lawyers this this document I'm showing you here is 19 pages it's an audit trail from an actual case that I'm involved with involving a three-day hospitalization at a local hospital here and it shows all the persons who access this chart and when they access the chart and I would I would say to you that this is something that gives persons the opportunity to get an idea of when they new information and how quickly they reacted to it by identifying when they went into the record and what could have been available to them at the time they went to the record and then when they actually documented whatever they did in that record so it's you know it is sort of a two-edged sword because this can also show a nice roadmap for when the care is proper because the care is is properly and appropriate and good and you know the vast majority of the cases of course so could I add something to the comments by the physician earlier in yourself about what is the record and I know it's coming up and some slides we have but again one of my Hospital clients to address the physicians point said it was imperative when we produced the records to try and do a screenshot of what the doctor initially looked at versus how the record ultimately is printed and we made did that from the get-go so they wouldn't become credibility issues later in terms of producing it now and producing it later also it's important whether you're the healthcare provider I think or the attorney working with them particularly during this time period of transition to make sure when there's a request for records that if there's an electronic portion you ask is this all the records sometimes you just get the hard copy sometimes the prescription is all electronic and they don't produce and then what could be a vital part of the record again thinking to my nursing home clients the MDS sheets in terms of the daily input and what is being tracked that's all electronic but there's another paper chart that takes care of other issues but you need to make sure you have the entire chart printed from the get-go and produced and then in the same a lawyer's weekly article there was a comment by Paul Manny is a well-known malpractice lawyer in town here who content defense is that's from the defense so you know with the reference to being familiar with the program the larger institutions that require training and then all persons who use EMR need to have persons who are familiar with this not only for accurate information but the completeness of the record and I think when we were meeting Dan and talking about what we're going to say dr. fregoli mentioned training is imperative in terms of what you were undergoing it is yeah so you know we spend a lot of time particular with our residents and our medical staff in giving them the tools to really understand and how to navigate the electronic health record the thing is I think to with you know the the current versions of the electronic health record there are places that you can document and there is somewhat of a silo of information nursing documentation can sometimes be siloed from physician documentation and that that narrative that story is somewhat lost and I think it's difficult even when you're it's difficult when obviously when you're caring for the patient sometimes and then it's even more difficult when you're trying to piece a story together from a paper record to to the comments that were made earlier and so you know we try to spend a fair amount of time using training programs for our residents and our medical staff and our nursing staff of course as well but it's it's really about understanding how the you know when a document is all about a fied how to best modify it so that you have good transparency of information and that it's very clear if there's late documentation that's put in that it aside from the audit trail that's present just so that it's very clear to the person who's reading the record in a contemporaneous fashion that it is a late entry or whatever the case might be and of course the the documentation issues of this actually goes back to the you know non EMR era era all of these issues are very critical in sense or prosecution of a medical malpractice cases how well are things documented is the documentation clear and all of these things still apply and I would add that the with the advent of EMR and the availability of programs that we have in our offices our office practice is the word search capability with EMR on a you know I'm at least from my perspective is much easier because you now have a more you have a greater number of records that can be integrated into your computer system for word search and for example if you have a case and it's a lengthy hospitalization or it's a number of hospitalizations you have thousands of pages of records and you put in a couple of phrases or word searches to see when for example the patient complained in angina or some other component you can find these terms more readily and I think that can assist in creating an outline for your evaluation of the case or examination of witnesses it's a two-edged sword because if there's no reference to a certain comment that that that may be bit detrimental as well but I think t e word search capability at least in my experiences has been helpful in getting through these massive records that when they're printed are probably three or four times larger than they were would have been before yes someone had tool and four item primary care so we have to do in my office is go answer what I call that be drawn run so they just look at the GFR yes is that helpful after a while you have this long list and if I were to search that then a given chart I could be busy for hours our end where you can see there are two thousand instances afraid this chart so again a beautiful a matter none of us so what we have to do is decision is not useful in terms of verification and well you know from my perspective when I'm looking for particular facts or non faxes of where it you know that that search issue can come up and it is a challenge because you you may pick the wrong term and you are going to run into this like the phrase BMI it might be just a category as opposed to what the actual figure was at a given point that that makes it makes a challenging I think there's a question oh I'm sorry just shout them out it's your document yeah you're the you're the final authenticating entity with the license so what they they're they're an unlicensed person they don't have any sort of clinical but most of them anyway I don't know in your situation but most don't have any sort of licensure at all so they are just basically taking what you and the patient are you know in a witness environment right they're just documenting what they're hearing but at the end of the day it's your signature and you're taking accountability and I can't speak from a legal perspective every right but you're taking responsibility for that for that note the doctor is absolutely right I see it a lot with my ophthalmology cases I don't know if it's because the a politics are trying to keep their hands-free but they're talking out loud and a non-licensed person is writing down the notes and as mr. Wolfmeyer cupry tell you because he's the pro in ophthalmology cases the ophthalmology terms can get pretty convoluted and you need to because you are ultimately the buck stops with you just like if I dictate something to my secretary if she gets it wrong and I sign off on it she's not going to be sued I am but you need to if you're using a scribe to get in the habit of looking over exactly what they did hopefully contemporaneous went with what they was with when you dictated it or said it because you will be held responsible yes all right it's part of a part of this training that was that mr. Mannion alluded to in his comment yes sir somebody's being sir our major hospital basement after Elliot because I touched upon but because the most critical issues that were required to review it and then you can make a late entry correct does that significantly reduce the liability issue in respect to the attorneys ability to review that well you know the late entry is one of those you know sort of dilemmas you know because on the one hand you don't want it to look like you've had no added things after the fact but the point if it's if it's a legitimate true accurate change you know you it's documented that's when it's done if this is done you know reasonably soon after the initial entry I mean that's just that's a more defensible proposition than putting no entry at all because when it's no entry at all to alter that or to change that alter Pitou to augment that comment I mean you you don't want to be asked two and a half years later in a deposition well this really occurred or this additional information was available why didn't you put it in then which is a bigger problem and those types of issues that give you know Jenny and I heartburn at night when we have to deal with that so my only my only caveat to Dan's comments would be don't ever make a late entry after litigations soon yeah you know it's really late entry I always right yeah I always wonder the better you could still remember it I mean what sometimes when once the lawsuit comes in there is clarity and you remember something that happened but as I tell the healthcare providers you can always supplement your chart at deposition and say what you remember what your normal habit routine and protocol is just because you remember it and it may in fact be true don't add anything after litigations in food you can do that at that position right okay and so you know the documentation issues we talked about obviously can affect whether the case sounds an ordinary negligence and professional elegance and this is this is a this is a big big deal professional potentially because for those of you that are not intimately familiar with the statutory distinctions in allowing damages in certain cases medical malpractice cases have caps or limitations on non-economic damages which are the pain and suffering and those types of damages loss of companionship of family members which are often very you know emotionally charged and there's some there's different levels of caps they won't have to get into that now but in an ordinary negligence case such as an auto case for example there's no cat there's no caps on these damage their unlimited they're left to the jury the jury's discretion and if a certain health care related issue is an ordinary negligence case it's a much easier task for the plaintiffs lawyer because a there's a limited there's no limitation on damages and the need for expert witnesses is is not as significant as well and it's when we get into issues of what I would call clerical management of health care treatment we are kind of getting into this uneasy potential gray zone of whether this is an ordinary negligence case or a professional negligence or malpractice case and in a very general way a malpractice case is founded on the analysis that the physician is using professional expertise and professional judgment and we have had cases over the years and Jenny I'm sure can talk about this with some of our nursing home cases where you have issues of man or I would call paraprofessionals assisting people and walking or getting them out of bed or issues of this nature which are maybe closer to ordinary negligence and it's it's a tussle but with respect to EMR I think you have yet another clerical or non potentially the involvement of a non professional where it's not an issue of rational judgment it's an issue of not physically doing something or putting something in the record so that's another thing to think about I don't think it's anything to get panicky about but I think it's out there potentially and I've seen this a couple of times with just simply phoning in a prescription the the dosage is phoned in wrong or the pharmacist hears it wrong and if the patient unfortunately has an adverse reaction to the mistake in the script I think it's a legitimate argument by the plaintiffs to say that was just ordinary negligence they phoned it in wrong they typed it in wrong that didn't involve any medical judgment so it puts it again in that ordinary negligence category without caps without the need to do and notices intent or affidavit of Merit a lot of the things that we like to see the plaintiffs jumping through all those hoops but documentation simple documentation errors I think it's a pretty easy argument that it's sounds and ordinary negligence as opposed to medical malpractice so you need to be cognizant of that and we have you know the benefits and you know this was we have a question result everyone but a physician you get your genetic testing results back they don't talk about you know get into the physician and the patient but we are finding I think that a lot of civil legislators are now trying to get around what Hitler and the Jena requirement by patients entirely the right to have an information versus either the employer to providing reduce insurance or material superficially quickly only treating physicians as all how to prevent that 2010 edition yet by kind of kill it tongue I don't think patients wanted out we used to fear I don't think what this is one day that they prepare you know what the revolvers are your today scary Stephanie the excesses so what are the happy even if it does for us our records all be available free only to go into the system so we send the position a hard copy what's the suggestion that they make for to your back many is socially identified as a better maintained in hard copy to your life that opens up that's a big can of worms isn't it yeah when you start releasing information to two payers and employers especially when it comes to you know genetic testing etc that does add I don't I really don't know I don't have [Music] no hope of genetic testing results and and I'm like Jerry dinner I think I'm going to be going to information of power and that giving your patience every bit of information they do to design how Brussels or how Castle they want to be you deal with problems why would you do that it's a it's a very interesting issue is with multiple waivers issues we're going to try to move along here you know the benefits of the records we've talked a little bit about this it is designed it was designed as a savings of healthcare costs and the benefits included that you know the reduced errors obviously the legibility is a very very significant point and the access to the record will allow you to know what tests have been done and it raises this other issue we've talked a little bit about before do these records really they really cause poor outcomes or do they cause claims which is I think an important distinction and as one of the things we've talked about I think is a lot of this these issues have resulted in issues dealing with claims as opposed to necessarily a bad patient bad patient outcomes or bad care so it's we talked a little bit about the alteration issues and the alteration of a medical record whether it's a paper record or an electronic record will contend contribute and trigger a sanction or a find by the licensed physician under the statute here and this is obviously one of the big things that we as counsel are concerned about if there's alterations of records and this is a felony under in law and something that the Attorney General I think is very sensitive to as as well as some of the opioid issues that we've talked about if I could just not to correct my wonderful colleague but I think later on the alteration statutes the MCL 750 point 492 and that all of the criminal says that's the permit right and civil is it can impose civil sanctions up to ten thousand dollars as well as a misdemeanor or a felony what's quoted for you on the screen the MCL three three three this is from the public health code and this is an allegation I see almost invariably in the licensing work that I do I do a lot of investigations for the state it's by the Attorney General working with your board of medicine whether it's the deal board the m.d. board the nursing board the psychology board but this is not as so much to do with amendments or changes this as you see says you must mean the physician or licensee has to keep a ship must keep a full and complete record of tests examinations performed observations and treatment made think about how onerous that is the language that's used and I'll give you a quick example of how this came to be with one of my doctors I represented a wonderful family medicine physician and taking care of a patient for 20 years the patient had multiple comorbidities one of which necessitated referring her to a nephrologist the patient went to the nephrologist and she thought he was rude she went back home and typed on the computers you know anyone with a computer can file a complaint with the state and said I didn't like this doctor he didn't treat me well he didn't you know so the state investigated that but in investigating the claim against the nephrologist the state asked for a copy of my family medicine physicians chart to try and put the story in context the state ultimately left the nephrologist off but going through a 20-year record of care found that they didn't think the chart was complete that certain days or entries didn't include all the vital signs it didn't include her thought process as to why she had made referral to the nephrologist and they sanctioned her and we went we got through the hearing but again most of you probably know investigations by the state are not covered by insurance so this could be a very costly and painful experience for the physician or health care provider to get through they're paying out of their own pocket if experts are needed you're paying for the expert and it's a system with frankly no rules I mean I could talk for a day on my annoyance with the state but it's just a cowboy system there's no rules of evidence that you follow there's no real guidelines or boundaries but this MCL statute the three three three is almost always an allegation in every licensing matter that I deal with but the flip side of that just do you think that the the repetitiveness of these EMRs that we've talked about ad nauseam so far do you think that that augments or assists a physician in terms of the completeness of the record even though the completeness may be very repetitive and redundant you know it's a good point it might it might be time for copying and pasting I don't know so I mean with every problem there's maybe a silver lining yes Decker okay that's one of the reasons why the entries are so long and we got to know that 99% of what seemed to notice be relevant except for the very harm in that explain that and part of it again is going to complete the October 1 year 1 it is exactly more importantly the insurance companies don't accept a billing the doctor's bills or visit there's elements in the building there's a very complicated grid it was probably a thousands of combinations in that grid the doctor doesn't get paid for the cognitive that investment of cerebral pop you know it's his intelligence and assessing your problem with a single and bring to work they value what the doctor would be able to and a whole list open in relatively few relevant items of this you come to anxieties including social history social history is not document that you cannot feel at the high of movement there's a person the amount of injuries items are so many little complications satisfying it so what happens is is you have come to the relevant information to satisfy you don't care it started with Medicare but the others are doing that so then at the end what you're left with is that is because and also a limited time to do that whole visit you are not having oftentimes missing off the bill build the office and going through the offices that'll be good an excuse at a trial table with all this extra nominal is e irrelevant it may not be correct but we did it to satisfy some other length excuse me that well it's part and parcel of why you were going to be you're going to be asked questions about redundancy and that that's part and parcel of that you just have to just have to be explained and I just let's wipe it off so first aid well but but then it becomes more of a challenge to you know for the defense to you know prepare appropriate motions in lemonade a deal with those circumstances and try to you know minimize some of these arguments because they really don't pertain to their care the presence of delivery of care is here there's administrative issues of payment issues that really have a not particularly critical in a malpractice trial so I think there's some ownership that its positions we have to take in the medical record especially in talking about a multi contributory environment like a hospital right where you have you have different disciplines documenting in the same place things like the problem is say I guess it all depends on where you practice but the problem list in our organization is owned by the physician the physician owns the facility problem list is wrong then it's our responsibility to correct it and so and then ultimately our note whatever we populate because the electronic health record gives us the advantage today to pull in information that has been documented by other people right and when we decide to populate our note with that information we are taki g a responsibility to assume that that is correct it's not just a matter of Auto populating and getting that information to a note at the end of the day I'm signing that note and saying that that's that information to my knowledge is accurate and so I think that's where I you know where we start getting in these notes that are extremely voluminous and and they lack relevance to your point it's really I think we're getting to a point now there's some sophistication and our understanding of how we should make these notes is sometimes a little bit is more and making sure that the information is meaningful and I think the EMR vendors are getting to that point as well and helping us construct these notes that are more meaningful but more impactful and I think you know technologies like Dragon voice recognition helps to tell the story in a narrative fashion and you know it helps us to you know carry that to carry the message across to the next person who's caring for that patient because if you take away regulatory legal and and financial the note is going to be you know two sentences if you need it from a clinical perspective there you don't need a lot in there to indicate which it would do what you want to support and your in your note but it's because like you said you've got to have so many bullet points from this element of you know past medical history social history review of systems that we it's kind of been indoctrinated in our way of pulling in all this information that makes the note less relevant but I just want to make one other comment and this is really important and I think you know we're moving into a new era where we think that the medical record is only the screen that's in front of us but in reality within health information exchanges which now taps us into information that is present not only at my organization or your office but also now the availability of this information at any organization the patient goes to because this information now is being sourced in a sort of central place that we have access to so as I clear taking care of a patient right and I you know I go into into the into the health information exchange portal and I see the patient had a cat scan at a hospital down the street and I use that for for medical decision making I need to document that in my note that I've pulled that information from from another source that's maybe not in the immediate medical record that's present because it's a federated model which means unless I pull that note into my into my record it's an external document because it's happened somewhere else but I'm using that information to make decisions so I'm going to have to incorporate somehow make reference to that so that I have I have a way of substantiating my decision making excellent point excellent and you know obviously it is you they listen to doctor for goalies comments like my mindset is okay when I would get a chart from a client an office chart and you see the correspondence from other physicians or consultants to whom the patient had been referred or x-ray reports or EKGs or other alt well called off-site testing was all there in the record so he came he had this x-ray report he had this EKG well now it's not so simple because you might not necessarily print and create that document in your chart so again another other things that you have to now change your mindset about both in practicing and defending these cases we talked about that yeah I'm sorry go ahead that is the biggest that you could I see gained 11 years during a time that you certainly save you time in this any minute is a question about that and if you haven't way that tradition which is a question you cannot as a capacitor a logistical Dartmouth whatever I write supposed to do right until the age of 40 attorneys leaders and 70 in the hospital so that is the time definitely is definitely the other sheet are there letting go same time it definitely works I am I not right it ain't on me EMR was not designed to do a bet to be a bad thing but I'm designed to be a good thing and points out these checklists are now available and other items here okay now we get into you know some of the anecdotes comments and things that you know come up and you know we have would be more the automatch problem when you start to type in things and the wrong drug gets kicked in I know that there's there's been discussion and some of the literature on this topic about alerts you know where in the hospital setting there might be alerts that come up and vendors make decisions then there's many of whom are not being run by actual people that put their hands on and treat patients creating these warnings that sometimes interfere with care and that becomes can become a nightmare in a litigation setting and then we have you know you have the templates they can create that could create more accurate documentation but they're not all the same and you get these odd-looking charts like the the chart will say presenting presenting symptoms are none and you know it just it's hard to read it's just you're reading this note and you're saying is this is just this really happen or is it just a template and you again is dr. fregoli said you have to wade through these you know line after line of things that don't make a whole lot of sense to find the real need of it and this is this is something I actually talked us out to the panel here or maybe to the audience and I I've had in in dealing with these issues I have a sense that because you have a business in an industry where the software and the development of these templates is is in a period where there's a lot of different vendors with a lot of different templates to do this or is part of the problem is that the software provider the software providers are so numerous there's there's not good uniformity and how these EMR are prepared or how they're generated or how they're done and it just seemed to me that is the industry matures and fewer and fewer vendors are then doing this are you going to have more standardization in these templates and that's a rhetorical comment I don't know what the what the group may consider about that popular writers of programmers discovery and they need to hear from the actual texture about what should and cetera go all their little Brainiac all weekend is coming up with new programs as well for your hospital corporations so a little principle embodied down there and evidences week is and tell them what you really need to do your job better and not waste your time a few little things so that you know they can do better job really worked at the program because they don't know it won't be is it and although to the desired run after lows and extra program in their program you see the source of information okay and then also spent all this money on the dentist's nothing to report okay so so we have we had you know the issues of the templates and the dependence on those the cut and paste issues we talked a little bit about that I would hope I could add onto the template discussion and I see this a lot in the ER the patient comes in and it makes me think back to the old TSheets let's do you hold a tea sheet for neurology trying to rule out the PE or do you pull the tea sheet for a cardiac condition and case you're dealing with a dissection and if you God help you if you pull the wrong tea sheet because it leads you on a path to either go neurology thinking or think cardiac thinking but if you're getting into the same thing with templates where its leading you or suggesting once it's printed that your thought process was going one way and you weren't even thinking the other thing rule out PE focus on cardiac if you have a line at the bottom a space to do anything to type in one sentence to individualize that patient or to supplement what you were thinking with what the template restricted you to it would be you may save yourself a lawsuit to take the two minutes to ended type in some sort of information that individualizes that patient and shows you weren't just thinking within the confines of the template I couldn't agree I couldn't agree with that comment more it's a very very very important that the free texting or the opportunity to type in and it is done and I think you know I think even most plaintiff's counsel are going to focus on that well because I think that you know some of these repetitive issues are or not as significant as what that particular encounter and what the particular physician had in mind puts in the chart okay we talked a little bit about the audit trails I think we've mentioned that and this is also the citation of the statute that Jenny was talking about before we're kind of getting near the end here so I'll try to try to get through the last couple slides quickly we talked about inpatient relations the access to data some of these things that doctor for goalie has pointed out and the access of these access to other providers records and how it may or may not be actual visit actually be visible in the particular physicians a record and then the privacy issues the the communications have required the passwords and the risk of unoccupied workstations where I mean I haven't seen this in my own experience but I could see how in a hospital setting someone's on the screen and they wander off not wander off but are distracted and then the potential for for inappropriate material or inappropriate access is occurring and I would also assume that licensing issues would come into play because physician's assistants or other para medical professionals would not have the same legal with it wouldn't be proper for them to do things that would be limited to the parameters of the physician so if I can just make one one brief comment about credentials your credentials your electronic credentials it doesn't happen very often but there's that temptation to you know you're working with a resident or a student or whatever and to share credentials with anyone other than yourself is a huge problem yeah it's to protect yourself to you should never give your username or password if you're a clinician to anyone because it's like giving them you you know all of your your personal information and access to your bank accounts etc because they you know it from when the record is printed it looks like it's you it is you it for all intents and purposes and so you're assuming all of that as work that you have done so be very careful and avoid that the temptation to sometimes just it's just easier to give them especially if you're not proficient in in using the electronic health record it's just easier to give it to somebody else or let them do it that my best advice to you is to prevent that avoid that from happening the doctors absolutely correct as always that I recently attended a seminar on cybersecurity and they said the number one best piece of information if someone's going to do identity theft is a medical record more so than your bank statements more so than your credit cards more so than socials just having a social security number the medical record is the number one target for identity theft people so we we need to know you obviously talk about what's a paper chart what's in the EMR and the production of records often will include both the request for EMR and sometimes the the office will have kind of two files or maybe hard copies and there may be electronic so making sure both of them are provided is because if there's one thing that defense lawyers well there's many things that defense lawyers worry about but one of them is did I get the full record do I have the full char do I have everything in front of me so that I can counsel my client prepare them for deposition or trial or whatever it may be and I can tell you because I've been there is that there's nothing more disturbing at a deposition when you are finding out that there are additional records that were not provided which may or may not be helpful and sometimes this has happened the plaintiff lawyers will have requested the record from your client independently and they were provided without seeking counsel and not that that's required and they've got stuff in the deposition that I haven't seen and that's very that's very discomforting so having someone available or trained and knowledgeable or at least someone available to ask the right questions when documents are requested is very very important especially in this era where the record is is not always just a tangible item so obviously we talked about the credibility issues the charge is not initially provided and the designation potentially of persons trained and I think we've had some questions but I know if we have a couple of moments for a couple more anyone anyone okay very good thank you very much I think it's come back [Applause]