The Use Of Electronic Medical Records In Social Security Disability And SSI Claims Presents Unique And Challenging Evidentiary Issues.
We are all used to modern healthcare visits in which doctors and other health care providers sit in front of a computer screen, ask us questions about our health and medical history, and then busily bang away on the computer keyboard. They are creating Electronic Medical Records (EMRs) that chart your care.
You may have noticed that the interviews are quite repetitive, and often begin with a nurse or physician’s assistant asking you the same questions you were asked at your last visit. You may also have noticed that the doctor seems to be hitting the Tab or Enter key on the keyboard to race through field after field. What is going on?
EMRs require physicians to perform their own data entry, and the EMRprogram’sdata entry protocol rather than the doctor controls the format of the visit. What had once been a note jotted into a paper record, now involves a dozen or more mouse clicks or keystrokes to navigate a complex EMR workflow set of screens. During your visit, you may have been asked dozens of questions, with very few having anything to do with why you are there in the first place.
Healthcare providers can be prone to taking shortcuts in entering the data, or not entering it in a timely manner. Vital sign data is often duplicated as it moves between hospital departments, but it remains part of one integral patient record. Data administrators also may copy and paste patient information from an older record to a newer one, supposing that the data would remain the same. And the sheer complexity of EMRs poses issues with accuracy, as being able to track who has entered what data, and when, over time can become confusing.
When an electronic medical record is printed out, the amount of repetitive data in it is overwhelming.One very good doctor I worked with on a case explained that, in reading her exhaustive office visit notes, I should look only at the boldedtext to see what was not simply automatically pasted in from previous visits. There was not much boldedtext in page after page of findings and observations. There were, however, numerous negative findings from what appeared to be comprehensive neurological testing conducted during each office visit. The findings were automatically brought forward by default from the one comprehensive test that had occurred at the outset of treatment. These kinds of “findings” that are no more than default entries in the EMRs have been fatal to disability claims.
Lucas Mearian recently wrote an article in Computerworld that explored how these faulty EMR records are also leading to negligent treatment based on erroneous data entries. It is an interesting read.
These are the records we are required to submit in their entirety in your case. At Goss & Fentress, an ever increasing amount of our attorney hearing preparation is dedicated to reading every page of these records in order to prepare a useful summary that extracts what pertinent information there is in EMRs and finds the data errors in them that should be disregarded. This then takes the form of either an opening statement or written brief for the Administrative Law Judge.
It’s a nasty job but, as the saying goes, somebody has to do it if you are going to win your case.