Narrative Review of Electronic Health Record Systems in Anesthesia: Benefits, Risks, and Medico-Legal Considerations in the United States of America.

Electronic health records (EHRs) have transformed healthcare delivery and documentation by accurately capturing routine care and critical events through automated data recording. EHRs also enable clinical decision support, quality improvement initiatives, and large-scale research. A narrative review...

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Publicado en:Journal of Medical Systems Vol. 49; no. 1; pp. 1 - 12
Autores principales: Tewfik, George, Minzter, Beth, Chiao, Franklin, Zivot, Joel, Wecksell, Matthew, Simpao, Allan F., O'Reilly-Shah, Vikas, Berg, Kent, Wang, Ellen, Tan, Jonathan M., Ondecko, Kristin, Banoub, Mark, Pesce, Michael, Khatib, Reem, Abola, Ramon E.
Formato: review tables/charts Journal Article
Publicado: Springer Nature 6/23/2025
Acceso en línea:Ver este registro en EBSCOhost
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          Tewfik, George
          Minzter, Beth
          Chiao, Franklin
          Zivot, Joel
          Wecksell, Matthew
          Simpao, Allan F.
          O'Reilly-Shah, Vikas
          Berg, Kent
          Wang, Ellen
          Tan, Jonathan M.
          Ondecko, Kristin
          Banoub, Mark
          Pesce, Michael
          Khatib, Reem
          Abola, Ramon E.
        affil: https://ror.org/014ye1258 Rutgers New Jersey Medical School, Newark, NJ, USA
      sug:
        subj:
          Electronic Health Records Legislation and Jurisprudence
          Electronic Health Records Ethical Issues
          Anesthesia
          Documentation
          United States
          Decision Support Systems, Clinical
          Privacy and Confidentiality
          Consent
          Communication
          Liability, Legal
          Government Programs
          Negligence Legislation and Jurisprudence
          Metadata
          Audit
          Government Regulations Ethical Issues
          Organizational Policies
          Quality of Health Care
          Clinical Documentation Improvement
      ab: Electronic health records (EHRs) have transformed healthcare delivery and documentation by accurately capturing routine care and critical events through automated data recording. EHRs also enable clinical decision support, quality improvement initiatives, and large-scale research. A narrative review has been constructed using relevant research regarding medicolegal liability associated with EHRs, related to anesthesia care. EHRs have created new liability exposures through alert fatigue, system errors, and inappropriate use of functions such as copy-and-paste. Ethical issues and concerns with EHRs include privacy, informed consent, and secondary data uses. Metadata, "data about the data", provides insight into record authenticity, clinician involvement in care, and communication between providers. However, EHR metadata is legally discoverable, and courts have compelled its release to plaintiffs despite hospital objections. This narrative review covers the benefits of EHRs in anesthesiology practice, discusses medicolegal liability and ethical concerns, and highlights a method for assessing medicolegal risks using the EHR.
      pubtype: Academic Journal
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        review
        tables/charts
        Journal Article
      ougenre: Article
    language: English
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