Sloppy EHR Data Signals Need for Standards
Often, the problems have nothing to do with the evolving technology, but simply the process used by physicians and other healthcare providers in their utilization of EHRs. For instance, documentation produced by cutting and pasting information from previous patient visits "continues to be a significant problem" that creates "unnecessary redundancy and at times inaccurate information," Dougherty says.
"This can lead to clinicians checking off services they haven't performed or material being incorrectly copied and pasted," she told the committee. "If clinical documentation was wrong when it was used for billing or legal purposes, it was wrong when it was used by another clinician, researcher, public health authority or quality reporting agency."
Dougherty calls the improperly copied information as "cloned" material. That could include social, medical and family histories; visit/clinic notes, inpatient progress notes, consults, vital signs and reviews of physical exams. "We may need records [from] two years ago, but we need to know these records actually [reflect] what happened then and haven't been modified over time because of system updates," she told me.
Ivy Baer, senior director, regulatory and policy group at the Association of American Medical Colleges also expressed concerns about how the written record is being used in EMRs in testimony before the HIT committee. The AAMC represents all 141 accredited US and 17 accredited Canadian medical schools as well as 400 major teaching hospitals and health systems.
"Unlike a note written on paper, a note written in an EHR can be generated by using information that already has been recorded elsewhere," Baer told the committee. "The result can be a note that appears to be new and contemporaneous but actually is a combination of pre-existing material. Incorporating information that is not original to the author onto a note has the potential to jeopardize patient care and expose providers and/or institutions to liability."
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