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ELECTRONIC
TMB adopted the proposed rules on April 10 and published them
in the Texas Register on May 15. They took effect on May 20.
The rules spell out that physicians will be required to document
in the medical record any communications involving medical deci-
sions and must ensure “non-biographical populated fields” in the
record contain accurate information.
Dallas pediatrician Joseph Schneider, MD, chair of the Texas
Medical Association Council on Practice Management Services, in-
terpreted 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 communications 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 re-
ally need to be aware of clinical information that’s being pulled
in from other sources,” said Fort Worth pediatric emergency med-
icine physician Matthew Murray, MD, chair of TMA’s Ad Hoc
Committee on Health Information 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 responsibility to make sure that the information 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 summary or documentation memorializing any substantive
communication that is transmitted or received by the physician and
relates to the health, condition, diagnosis, treatment or care of a pa- to see instances of EHR computer systems that were pre-populating
tient, 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 language. Then-TMA Pres-
ident Austin I. King, MD, said the association was concerned about
“the administrative burden placed on physicians to compile all such
information, the potential negative impact to patient care caused by
excessive information in the medical record, and potential selective
enforcement of a rule that would have almost certainly been impos-
sible to fully comply with.”
He went on to note that the proposed standard that a communi-
cation in a medical record had to be “substantive” would have been
“difficult for physicians to interpret, leading towards overinclusion
(and its attendant problems) or well-meaning physicians failing to
comply with a rule (and subsequent enforcement).”
In early 2014, TMA asked the medical board to convene a stake-
MEDICAL RECORDS
holder group to examine the implications of proposed EHR rules
and alternatives to addressing the three problems that had been iden-
tified. The medical board assembled such a group last August. Mem-
bers included physicians, EHR experts, attorneys, community
members, and employees of state agencies.
The board’s new rule language on documenting patient commu-
nications underwent some tweaking before taking on its final form,
which requires physicians to document any communication the doc-
tor transmits or receives about which “a medical decision is made
regarding the patient.”
TMA was more supportive of the eventually
adopted language.
Dr. Murray says the final rule’s requirement that physicians doc-
ument communications with patients that involve medical decision-
making is sensible.
“The concern was over the possibility that physicians would be
required to record every conversation with a patient, which would
be burdensome and really wouldn’t add to either the quality of care
or to the accuracy of the medical record,” he said. “So with that dis-
cussion, we were able to at least narrow the communications down
to those that impacted decisions made on patient care, and it is rea-
sonable to include those in the medical record.”
To address the concern of EHR fields being improperly pre-pop-
ulated, TMB adopted a new subsection in the rule that states, “All
non-biographical populated fields, contained in a patient’s electronic
medical record, must contain accurate data and information per-
taining to the patient based on actual findings, assessments, evalua-
tions, diagnostics or assessments as documented by the physician.”
TMB Executive Director Mari Robinson explains the board began
test results as normal, even when the tests or evaluations hadn’t been
performed.
“So the board wanted to make very clear that the only type of
things that should be pre-populated are things like name, date of
birth, that type of information,” Ms. Robinson said, “versus this
idea of pre-populating an outcome of an evaluation or a test when
that has yet to be completed.”
TMB adopted the non-biographical populated fields rule provi-
sion despite concerns voiced by Dr. King in TMA’s comments about
the revised rules. He wrote the section “may be confusing to physi-
cians” and that the phrase “non-biographical populated fields” could
potentially be the biggest source of confusion.
TMA suggested changing the provision to refer to “all populated
fields containing clinical information” within the record.
Although TMB published that portion of the proposed rule as
originally drafted, it did decide to take TMA’s suggestion to publish
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