Currently, there is a bill making its way through the state Legislature that, for security reasons, would make it more difficult for health care professionals to make changes to electronic medical records (EMR) without leaving a record of the change.
Sen. Mark Leno, D-San Francisco, has stated in a May hearing that EMR changes can be more difficult to trace and can often go unnoticed as opposed to changed made to paper records. Sen. Leno is the author of SB850. The Senate passed the bill on May 31 and it is scheduled to be heard, in the next few weeks, in the Assembly’s Health and Judiciary committees.
Evidence of the need for such a bill was indicated by the case of Diane Stewart. Stewart died suddenly after having knee surgery a few years ago at the Stanford University Medical Center. A subsequent investigation revealed that sections of her computer health files had been deleted shortly after her death. It was also revealed that a nurse had been instructed to make entries regarding Stewart’s care after her death. This led Stewart’s family to level charges of a cover up perpetrated by the medical center in order to hide any errors in treatment. According to Hearst Newspapers, the medical center has denied any wrongdoing.
An attorney for the Stewart family, Christopher Dolan, has pointed out that health care professionals are not required to track changes in medical records under the current federal guidelines. In addition, records that are kept in electronic form are very easy to manipulate. This can make an investigation, in the case of medical malpractice, cost-prohibitive for victims. In cases such as those, the victims or their families would need to hire special investigators to address concerns of potential cover-ups.
The new bill, under consideration, would require any changes to an EMR to be automatically recorded. It would also require an indication as to who made the changes. Patients would also be able to see any changes that have been made to their medical records upon request.
However, concerns have been expressed by the California Hospital Association and the California Medical Association. These concerns revolve around the cost that would be involved to make the changes necessary to support this level of technology. It has been stated that the frequency of problems with EMR changes is too low to justify the expenditure that would be required to comply with the bill.