ELECTRONIC HEALTH RECORDS: FRIEND OR FOE PRESENTATION TO THE NORTHERN NEW ENGLAND SOCIETY FOR HEALTHCARE RISK MANAGEMENT Freeport, Maine November 13, 2017

Legal Framework Medical Malpractice Claims Regulatory / Licensure Investigations Personal Injury / Workers Compensation Peer Review / Credentialing

Legal Issues Who did what? What happened? When did it happen? Who knew / when? How can it be proved / defended?

Where Do Requests Come From? Subpoena Document discovery request Patient authorization Healthcare provider request

Any Legal Risks? With paper “record,” few With electronic “record,” many Page numbering Which dropdowns included Recreation of chronology Does it matter who requests it (healthcare provider? finance?) Format consistency Printed? On disc? Look over your shoulder? Different responders different results?

What About Patient Care? Do all have access to all records? How are reports integrated? Are there automated alerts? If so, who sees them? What if they are ignored?

Potential Impact Substandard record keeping Substandard medical care Legal problems Not complete Not consistent Create a legal problem Discovery Credibility

How Can We Mitigate The Risk? Understand what can / cannot be done Identify single POC / unit Define the “record” and communicate its contents Address the audit function – record or not? Train, train, train Communicate with each other Involve counsel Create a responsive plan for network penetration (back up) Create a litigation hold process

Questions/Discussion Ernie Babcock Eaton Peabody 100 Middle Street P.O. Box 15235 Portland, ME 04112-5235 (207) 274-5266 ebabcock@eatonpeabody.com