tions not being properly reflected in the medical record; and
3. Pre-populated fields in EHRs im- plying tests had been performed that, in fact, had not.
TMA adopted the proposed rules
“The volume of information that’s captured in an electronic medical record is impressive, but much of it is not clinically useful.”
on April 10 and published them in the Texas Register on May 15. They took effect on May 20. Read the new rules at tma.tips
/medicalrecordsrules. The rules spell out that physicians
will be required to document in the medical record any communications involving medical decisions and must ensure “non-biographical populated fields” in the record contain accurate information. Dallas pediatrician Joseph Schnei-
der, MD, chair of the Texas Medical Association Council on Practice Man- agement Services, interpreted the changes as an attempt to bring TMB’s rules into the electronic age. “We’ve got patients tweeting; we’ve
got them Facebooking,” Dr. Schneider said. “It used to be that communica- tions only occurred when you passed your patient in the store or you took a phone call. Now, there are all sorts of ways that communications are coming to a physician.” “To me, the most important thing
that stands out is that we really need to be aware of clinical information that’s being pulled in from other sources,” said Fort Worth pediatric emergency medicine physician Mat- thew Murray, MD, chair of TMA’s Ad Hoc Committee on Health Infor- mation Technology. “Whether we’re copying and pasting information from an old note to a new note or using templates that automatically bring in clinical information … it is our respon- sibility to make sure that the informa- tion that got pulled in is accurate.”
RULEMAKING ADJUSTMENTS As originally published in the Texas Register in January 2014, the rules would have required physicians to include in the medical record “a sum- mary or documentation memorializ- ing any substantive communication that is transmitted or received by the physician and relates to the health, condition, diagnosis, treatment or care of a patient, including, but not limited to, communications that are verbal or recorded and transmitted via any medium.” TMA had concerns with potential
unintended consequences that might follow the adoption of such rule lan- guage. Then-TMA President Austin I. King, MD, said the association was concerned about “the administrative burden placed on physicians to com- pile all such information, the potential negative impact to patient care caused by excessive information in the medi- cal record, and potential selective en- forcement of a rule that would have almost certainly been impossible to fully comply with.” He went on to note that the pro-
posed standard that a communication in a medical record had to be “sub- stantive” would have been “difficult for physicians to interpret, leading to- wards overinclusion (and its attendant problems) or well-meaning physicians failing to comply with a rule (and sub- sequent enforcement).” In early 2014, TMA asked the medi-
cal board to convene a stakeholder group to examine the implications of proposed EHR rules and alternatives to addressing the three problems that had been identified. The medi- cal board assembled such a group last August. Members included physicians, EHR experts, attorneys, community members, and employees of state agencies. The board’s new rule language on
+ 54 TEXAS MEDICINE July 2015
TMB’s new medical records rule: tma.tips/medicalrecordsrules
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