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Emerging Issue: Manipulation of Electronic Health Records

Medical records are perhaps the most important piece of evidence in most Illinois medical malpractice cases. A plaintiff in the case is required to show that the medical provider acted negligently by a preponderance of the evidence. That usually is accomplished by examining the medical records to show what care was provided, when it was provided, and how it was provided. That is then compared with reasonable standards–usually explained by an expert witness.

For this reason, each Chicago medical malpractice attorney at our firm understands the critical importance of ensuring consisted, accurate records are kept at all stages of the medical caregiving process. Of course, beyond providing a trail of care for future legal use, honest records are vital to ensuring proper care for medical patients.

The Problem
Unfortunately, some caregivers are willing to engage in unscrupulous conduct with medical records in order to cover up problematic care. Manipulated records have popped up time and again in various cases, including medical malpractice, nursing home abuse, and other settings where institutional care is provided.

Many now worry about the potential for widespread medical record manipulation with the promulgation of electronic health records (EHR). A recent story out of Australia illustrates the concern.

Thousands of EHRs Changed
According to a post at HC Renewal, an executive at a hospital recently admitted to altering thousands and thousands of records to falsely inflate certain hospital statistics. In particular, the executive admitted to making “twenty to thirty changes to hospital records” every single day starting in late 2010. The changes related to statistics like emergency room wait times and overall length of hospital stays.

At first officials suggested that the manipulation was motivated solely by the executive’s job security concerns. Yet, as more information came out the story shifted to pressure from higher-ups about needing to smooth publicly-reported information.

Floodgates Open
It is naive to believe that this is an isolated incident of EHRs being altered. Unlike paper records, the ability to access this data from anywhere at any time in an easily digestible way means that the temptation to alter damaging information might be too much for some to resist.

Beyond manipulation of hospital-wide data, our Chicago medical malpractice attorneys worry about the manipulation of individual patients on a case-by-case basis when medical errors are made. What is to prevent a practitioner or executive from making a few changes electronically to cover up the error and frustrate any future legal accountability?

With paper records it was a bit harder to alter records without leaving some sort of trail. And mass manipulation was nearly impossible. EHRs change all of that. Manipulation is now possible in easy ways that will be difficult to trace.

In fact, the only reason that this mass-manipulation in Australia was uncovered at all was that the responsible party was too perfect in his work, raising huge red flags for auditors. For example, much of the manipulation was does on the executive’s time off. In addition, an unusually high number of emergency room patients were seen at the “exact’ time frame for their illness category, like 30 minutes or 60 minutes.

See Our Related Blog Posts:

Evidence Links Electronic Records to Patient Safety Improvements

Timing Problems Lead to Medical Errors by Doctors