Tewfik George, Minzter Beth, Chiao Franklin, Zivot Joel, Wecksell Matthew, Simpao Allan F
Rutgers New Jersey Medical School, Newark, NJ, USA.
Cleveland Clinic, Cleveland, OH, USA.
J Med Syst. 2025 Jun 23;49(1):87. doi: 10.1007/s10916-025-02221-z.
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.
电子健康记录（EHRs）通过自动数据记录准确捕捉常规护理和关键事件，从而改变了医疗服务的提供和文档记录方式。EHRs还支持临床决策、质量改进计划以及大规模研究。本叙述性综述利用了与EHRs相关的医疗法律责任（与麻醉护理相关）的相关研究构建而成。EHRs通过警报疲劳、系统错误以及对复制粘贴等功能的不当使用，产生了新的责任风险。与EHRs相关的伦理问题和担忧包括隐私、知情同意以及二次数据使用。元数据，即“关于数据的数据”，能洞察记录的真实性、临床医生对护理的参与情况以及提供者之间的沟通。然而，EHR元数据在法律上是可被发现的，尽管医院提出反对，法院仍强制要求将其提供给原告。本叙述性综述涵盖了EHRs在麻醉学实践中的益处，讨论了医疗法律责任和伦理问题，并强调了一种利用EHR评估医疗法律风险的方法。
