Metadata

What is “metadata”?  Dr. Thomas McLean at NGMD New Media explains:

Like any computer, an EMR generates metadata during its routine operation. This metadata is functionally an audit trail of how the computer was used. Anyone who uses an EMR needs to realize that every time they open a document (including patient notes, medication lists, and radiographic images) their “digital fingerprint” is left behind. This digital fingerprint, which can be traced back to the physician with as much certainty as a normal fingerprint, is actually easier to detect than a normal fingerprint. Unfortunately, few physicians using EMRs are aware of the potential treasure trove of information available in metadata and how it might be used against them.

And how might it be used against them?

Because physicians leave behind digital fingerprints, it is possible to discover what information a physician reviewed. No longer can physicians write “wnl” (which lawyers usually translate as “we never looked”) into a patient’s chart and expect to get away with this minor deception. If a physician’s digital fingerprint is not on the laboratory e-file and the physician writes “wnl” in the patient’s chart, the doctor’s credibility will be substantially undermined. Not surprisingly, many third-party payors want access to EMR metadata – which will provide objective evidence as to whether they are receiving the quality of care they purchased.

This is something to keep in mind, but I’ll still take my EMR over paper charts any day.

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