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

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.

Fig. 1

Summary of major federal legislation and programs promoting EHR adoption

Fig. 2

Recommendations for EHR use provided by federal regulation and medical informatics associations

Fig. 3

Key recommendations for anesthesia EHR implementation and maintenance