While EHRs have seen a surge in popularity in recent years and have made it easier to see a broader view of a patient's care and medical history, it has not come without risk.
by Lori Holt in Documentation on Tuesday, October 29, 2019
What are some of the risks associated with EHRs?
Documentation in an Easy to Copy-and-Paste Model
One problem our claims department has seen is the appearance of “canned” records. This happens when a record is duplicated word for word on multiple visits.
Sometimes providers fail to proofread copied records and typos are perpetuated throughout multiple encounters. Duplicated records give the impression that the record may not represent what actually occurred. When the exact wording has been copied from the prior visit, it appears a detailed evaluation and exam were not completed by the DC.
A good rule of thumb is that, if stacked upon each other, and held up to the sunlight, your notes shouldn’t line up exactly. However, don’t be fooled by software that simply generates randomized text that restates the same thing with different words. Auditors are aware of this trick. They are looking for evidence of patient progress, not just new words in the note.
To avoid the appearance of cloned records, consider adding a statement to the subjective part of the record at each visit that is a quote of the patient’s own words.
Example: “Susie states, ‘I slept four hours last night before the pain woke me up.’”
You might also include a note about the visit number within the care plan.
Example: “This is visit 7 of 10 planned visits.”
Though it may take a moment to type this information into the record, these measures will go a long way in demonstrating that your notes accurately represent a patient encounter and that you provide high quality care.
When the EHR Software Malfunctions—Due Diligence Matters
There have been some cases in which EHR systems have inaccurately recorded patient data, according to an investigation by Kaiser Health News and Fortune magazine. It is especially imperative for a provider to review everything thoroughly to ensure accuracy in entering and transmitting patient information.
Tip: Check that correct patient data is attached to the correct patient record, that any orders or tests are actually sent—and are received by the correct person, and that any test results are received and tracked accurately.
Another issue that recently came up with our claims department is where a doctor accessed the records after becoming aware of a lawsuit. The system noted that a modification was made, but there were no actual changes to the patient’s record. The doctor only accessed the patient record to see what it contained. This is something our defense counsel has to explain to prevent the allegation of altered records.
Check Your EHR for Accuracy
With the potential risks associated with EHRs, how can you prevent these errors?
To ensure your EHR runs accurately and without problems, practices can make sure the system is doing everything intended for its use, suggests Lorraine Possanza, DPM, JD, MBE, director of the Partnership for Health IT at ECRI Institute. By testing the EHR, you can see any potential problems, whether incorrect patient information is attached to the record, or if tests are not being ordered or received.
You can also create contingencies to be prepared for possible problems, Possanza recommends, such as backing up and creating retrieval tools for patient data, or creating security measures to protect your patient information.
When to Report Errors with Your EHR
If you notice a recurring problem when tracking patient information or something that could potentially pose a danger or threat to the patient, document the problem and contact the manufacturer so they are aware of the issue and can work to address it and eliminate future errors.
You can also report problems to the Office of the National Coordinator for Health Information Technology at the Department of Health and Human Services.
Safety First: Take the Necessary Precautions
If you find yourself drowning in entering information into an EHR system and not spending as much time as you would like focusing on your patients, one option would be to hire someone to help input data. This could potentially reduce errors in entry due to an increased ability to focus on entering the patient’s information, in addition to fewer hands in the EHR.
Regardless, understanding your system and how it works, testing it for accuracy, and providing any necessary training is your responsibility.
Taking every precaution to accurately document patient information is beneficial for everyone involved—for you, your patients and your practice.
Death by a Thousand Clicks: https://khn.org/news/death-by-a-thousand-clicks/
Risks of EHRs: https://www.medicaleconomics.com/news/risks-ehrs