I’ve recently worked in a practice where I had serious concerns about some of the accepted practices. As a non-clinician I’m not qualified to make judgments about matters of patient care but I am confident in my ability to discern when processes lend themselves to being utilized improperly thereby exposing practices and institutions to liability.

Consideration of medico-legal issues should be given serious attention prior to EMR implementation so that workflows reflect best practices as well as adequately safeguard clinicians. Issues to consider include:

• scope of practice for non-clinicians
• documenting non-office visits
• capturing appropriate information for billing purposes
• protecting PHI

It’s important “the way we’ve always done it” is reviewed and adjusted so that clinicians are not inadvertently exposing themselves to misunderstanding. Ask hard questions about  your current practices and make sure that the answers are compliant with any pertinent regulatory agencies.

Questions like…

• Who will be responsible for refills?
• How will we dispose of printed information?
• Who will be responsible for placing orders?

Of course there are many other questions and the pertinent answers should guide your implementation and subsequent utilization of EMRs. Experienced consultants can provide excellent questions and guidance to make sure that your practice reaps the benefits of documenting patient care electronically while minimizing your exposure to liability.

For another perspectives on this issue:

http://www.acgroup.org/research/medicalliability.html