Although electronic medical record technology has been around for several decades, most healthcare organizations have only recently started converting from paper charts to EMR software. The transition, as physicians are learning, comes with its challenges – most associated with implementation and training. However, there are also legal issues to worry about when adopting an EMR and it is important that these issues do not go unnoticed. Here are a few common risks that any health IT attorney or IT technician should warn physicians about.

Malpractice claims. The risk of medical malpractice is higher during implementation and in the weeks and months immediately after, especially for caregivers who do not receive proper training. Because physicians must learn a completely new system for charting, it can be easy for important data to be left out of a chart or even overlooked. When this happens, patients’ health can suffer. For example, if a physician fails to see an abnormal lab result because the test results are not easy to find in the EMR, the patient might not receive a medication necessary to improve their medical condition. Health IT attorneys also warn that malpractice claims can stem from:

• Data entry errors. From entering data into the wrong patient’s chart to transposing numbers or selecting the wrong item from a drop-down list, electronic medical records are not entirely error-free. Physicians should chart carefully, especially when first starting out with the EMR, as even a small data entry error could cost a patient greatly.
• Alert fatigue. EMR software often produces alerts and warning messages that physicians are not accustomed to seeing with paper charting. Some of these alerts are important and others are not – and not all physicians know how to change the frequency and the type of alerts that appear on their screen. Oftentimes, this leads to important alert messages being overlooked. If a physician fails to see a drug-allergy interaction warning, for example, they could end up prescribing a medication with adverse reactions for the patient. Mistakes such as this one can make physicians susceptible to malpractice suits.

Security breaches. With EMR systems, thousands of health records are stored within one central database, making it possible for more patients’ protected health information (PHI) to be accessed more easily. This is a good thing for doctors who are able to switch between patients’ charts at will. However, if an unauthorized person gains access to the EMR they could potentially view information for every patient in the EMR database. Security breaches typically occur when devices containing PHI are lost or stolen; but a data breach can also occur when an employee views information that they shouldn’t have access to.

Are you unsure as to whether your EMR is HIPAA compliant or your practice is susceptible to one of these risks? Contact a health IT attorney or EMR law expert to find out.