When Your EMR Makes You Lie

The ability to select from a menu of text entries rather than having to enter, for example, a statement like, "Patient doesn't have an email address.", increases the efficiency of electronic medical records (EMR). But some such software forces the user to enter false information. Suppose that patient actually does have an email address, but I prefer not to enter it into the record. The EMR might make a liar out of me. In this example I can enter something absurd like "a@b.c" to fool the software, but I would prefer to just leave the field blank.

My particular cloud-based EMR will not allow me to enter this frequently appropriate "reason" for denying a prescription refill request: "Change in dose or directions." Rather than lie by choosing a different selection I can just leave the request in the inbox. So far I only have seven.

What's the big deal? EMRs differ from old paper records in more ways than most appreciate, especially, I believe, most lawyers, judges and juries -- and even expert witnesses. Credibility counts for a lot in a malpractice case. If a plaintiff can demonstrate that even one aspect of the medical record constitutes false information, she will undermine the credibility of any records from that EMR product as well as testimony that relies on those records, likely contributing to a judgement for the plaintiff.

Smart EMR designers will never force the user to enter false information into their product. Instead they will simply allow the user to add custom selections to the menu or to fill in a blank with free text.

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