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Errors in the Record

Scott Mace, for HealthLeaders Media, December 13, 2013
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This article appears in the December issue of HealthLeaders magazine.

The move away from paper medical records to EHRs has many benefits, but the flip side is that providers need to carefully manage the usability, accuracy, and audit trails of EHRs across the entire care team.

Providers say the day of the doctor carefully controlling and supervising every aspect of a medical record is giving way to an age where the entire medical team and even patients will scrutinize and update a record's accuracy, all while legal and regulatory requirements for maintaining those records are met. At the same time, the complexity of EHR software itself increases the risk of EHR-caused medical errors.

While EHRs have been around for years, the requirements of meaningful use stage 2 for patients to be able to view, download, and transmit their medical records to providers across the care continuum as well as health information exchanges mean it is time for providers to pay special attention to proper record maintenance.

Dealing with errors in the record is coming to the forefront of these concerns. "Traditional practices within the paper record support a single-line strikethrough of the original documentation," according to Amendments in the Electronic Health Record Toolkit, a 2012 paper published by the American Health Information Management Association. "However, these practices will not necessarily transfer to an electronic environment, and new practices should be evaluated against organizational policy and specific system limitations."

AHIMA's paper also advises: "Processes for receiving the patient amendment request identifying PHI affected, determining whether it should be accepted or denied based on the type of request, and notifying the patient of the outcome must be developed."

Further complicating the picture: As physicians move from clinic to clinic or hospital to hospital during their workday, they are using EHRs from multiple vendors, and each EHR may express discrepancies in the medical record differently.

"They may have multiple different interfaces to deal with," says Blackford Middleton, MD, chief informatics officer and professor of biomedical informatics at Vanderbilt University Medical Center, a 626-licensed-bed hospital in Nashville.

Although EHRs improve quality and patient safety and are known to reduce costs, there may be problems associated with their use, and they can even cause medical error, he says.

Middleton likens the abilities of today's EHRs with those of the challenges of using word processing in the late 1980s, when such software ran into usability and interoperability problems.

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