Medical records are integral in defending against allegations of negligence and substandard care, but only to the extent that they are complete and accurate. Considering paper records still exist and that most health care facilities and providers utilize electronic health records (EHR) which are comprised of multiple internal and external systems that have to “talk”, there is a likelihood a patient’s record could be missing information critical to your case.

Duplicate data in medical records

Incorrect patient identification (matching a patient to their medical record) is one of the most prevalent issues threatening the integrity of patient data in healthcare organizations. It can occur any time a patient has an interaction with a healthcare professional. This could be at the time of admission, before a procedure is performed, or when a specimen is collected, for example.

Many factors contribute to these errors. The cause can be as simple as pulling the wrong chart because two patients share a similar name. Sometimes, numbers in a date of birth or Social Security number are transposed while looking for or creating a medical record.

Three common medical records issues that can result from incorrect patient matching are:

• Duplicate records: One patient has two or more medical records containing different information within the same facility, resulting in impartial and inconsistent medical histories and information
• Overlay: Two patients share the same record or their records are incorrectly merged together
• Overlap: More than one record exists for a single person in two or more facilities within a hospital system.

Dangers of duplicate medical records for healthcare organizations

The reason duplicate medical data is challenging for healthcare organizations is that it can compromise clinical decision-making. An example of the problem duplicate records can cause is provided in the article, Using Health Informatics to Tackle Duplicate Medical Record Issues:

“A physician may locate two records for a patient and select only one of the records as a reference for how he/she would administer treatment for the patient. This physician could then prescribe a medication for the patient that produces an adverse reaction, causing the patient to be referred for emergency treatment.”

Health care facilities spend millions of dollars annually to address the duplicate problem, through personnel and IT solutions. The government, regulatory agencies, and professional organizations are all involved in initiatives to resolve duplicate records.

The Office of the National Coordinator for Health IT (HealthIT.gov) states:

“Duplicate records caused by a lack of patient identity integrity, most often occurring at the point of origination through the registration process, can affect treatment, testing, insurance claims, and billing. The demographic data about a patient is a critical data set, and its reference and usage throughout the healthcare lifecycle is ubiquitous.”

 

Issues duplicate medical records pose for defense attorneys

Duplicate records pose issues for defense attorneys because they use medical records to evaluate the validity of a claim or allegation, determine case value, and form a defense strategy. If they are working from partial, incomplete, or inaccurate records, they may not know they aren’t reviewing the complete story of patient care. They may only have one of two or more of a patient’s medical records, or they could be looking at a record that contains the medical history of two different individuals.

If an attorney doesn’t have a medical background or access to a team member who does, this situation could be a huge setback, costing them precious time and resources. In this case, utilizing third-party health information management (HIM) professionals to review available records is a good way to start case preparation. HIM specialists are trained in all aspects of medical record documentation, including, but not limited to:

• identifying inconsistencies
• finding gaps in time and treatment records
• comparing billing and supporting medical data
• verifying that physician orders correspond with lab work, pharmacy and other ancillary records.

How Excelas can help

The HIM specialists at Excelas can identify missing information early in the record organization and analysis process, allowing counsel to request additional records from the health care provider in a timely manner. Access to complete and accurate records will help uncover data that can be used to inform strategy right away.