Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2025 Jun 23;49(1):87.
doi: 10.1007/s10916-025-02221-z.

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

George Tewfik  1 , Beth Minzter  2 , Franklin Chiao  3 , Joel Zivot  4 , Matthew Wecksell  3 , Allan F Simpao  5 ; CIIT Collaborators
Collaborators, Affiliations
Review

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

George Tewfik et al. J Med Syst. .

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.

PubMed Disclaimer

Conflict of interest statement

Declarations. Ethics and Consent to Participate: Not applicable. Competing interests: The authors declare no competing interests. Prior Presentations: None. Clinical Trial Number: Not applicable.

Figures

Fig. 1
Fig. 1
Summary of major federal legislation and programs promoting EHR adoption
Fig. 2
Fig. 2
Recommendations for EHR use provided by federal regulation and medical informatics associations
Fig. 3
Fig. 3
Key recommendations for anesthesia EHR implementation and maintenance
See this image and copyright information in PMC

References

    1. Peters RM. Interactive microcomputer for acquisition of patient information. Article. Journal of Clinical Monitoring. 1989;5(4):266-269. 10.1007/BF01618259 - PubMed
    1. Kadry B, Feaster WW, Macario A, Ehrenfeld JM. Anesthesia Information Management Systems: Past, Present, and Future of Anesthesia Records. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine. 2012;79(1):154-165. 10.1002/msj.21281 - PubMed
    1. Simpao AF, Rehman MA. Anesthesia Information Management Systems. Anesth Analg. Jul 2018;127(1):90-94. 10.1213/ane.0000000000002545 - PubMed
    1. Lee R, Hitt J, Hobika GG, Nader ND. The Case for the Anesthesiologist-Informaticist. JMIR Perioper Med. Feb 28 2022;5(1):e32738. 10.2196/32738 - PMC - PubMed
    1. Colquhoun DA, Shanks AM, Kapeles SR, et al. Considerations for Integration of Perioperative Electronic Health Records Across Institutions for Research and Quality Improvement: The Approach Taken by the Multicenter Perioperative Outcomes Group. Anesth Analg. May 2020;130(5):1133-1146. 10.1213/ane.0000000000004489 - PMC - PubMed

MeSH terms

LinkOut - more resources