Sloppy EHR Data Signals Need for Standards
Software advances and dictation tools also can lead to problems, Dougherty says.
Some software enables doctors, with a single mouse click, to check a box indicating that all body systems were examined and found to be normal, even if that isn't the case, she says. And the dictation tools force physicians into the role of an editor—a self-editor.
Transcribed reports are often the most frequently used and exchanged medical record documentation, according to Dougherty. AHIMA members report that errors in all voice recognition dictated reports include incorrect diagnoses, age and other demographic information or facility name, she says.
"We're hearing that this dictation is forcing physicians into an editor role and is resulting in many errors," Dougherty says. "In the old method, they used to hire transcriptionists, dictate it and then provide the review. What is lost now is any type of editor."
The comments illustrate that as the government moves through its stages of Meaningful Use, the picture of EHRs is still blurry and must be resolved to ensure proper patient care and monetary rewards that are tied to quality.
"The importance of accurate information and documentation in EHR systems cannot be overstated," Dougherty stated.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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