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

IF 5.7 3区医学 Q1 HEALTH CARE SCIENCES & SERVICES

Journal of Medical Systems Pub Date : 2025-06-23 DOI:10.1007/s10916-025-02221-z

George Tewfik, Beth Minzter, Franklin Chiao, Joel Zivot, Matthew Wecksell, Allan F Simpao

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Abstract

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.

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麻醉电子健康记录系统的叙述性回顾：在美国的益处、风险和医学法律考虑。

电子健康记录（EHRs）通过自动数据记录准确捕获常规护理和关键事件，从而改变了医疗保健服务和文档。电子病历还支持临床决策支持、质量改进倡议和大规模研究。我们利用与电子病历有关的医疗法律责任的相关研究，构建了一篇叙述性的综述。通过警报疲劳、系统错误和不恰当使用复制粘贴等功能，电子病历已经产生了新的责任风险。与电子病历相关的伦理问题包括隐私、知情同意和辅助数据使用。元数据，即“关于数据的数据”，提供了对记录真实性、临床医生参与护理以及提供者之间沟通的洞察。然而，电子病历元数据在法律上是可发现的，法院不顾医院的反对，强制向原告公布。这篇叙述性综述涵盖了电子病历在麻醉实践中的好处，讨论了医疗法律责任和伦理问题，并强调了使用电子病历评估医疗法律风险的方法。

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来源期刊

Journal of Medical Systems 医学-卫生保健

CiteScore

11.60

自引率

1.90%

发文量

审稿时长

4.8 months

期刊介绍： Journal of Medical Systems provides a forum for the presentation and discussion of the increasingly extensive applications of new systems techniques and methods in hospital clinic and physician''s office administration; pathology radiology and pharmaceutical delivery systems; medical records storage and retrieval; and ancillary patient-support systems. The journal publishes informative articles essays and studies across the entire scale of medical systems from large hospital programs to novel small-scale medical services. Education is an integral part of this amalgamation of sciences and selected articles are published in this area. Since existing medical systems are constantly being modified to fit particular circumstances and to solve specific problems the journal includes a special section devoted to status reports on current installations.