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Electronic Health Records (EHRs) – the solution to some of the most pressing healthcare issues and the contributor to many more. Recent years have seen an increase in EHR utilization within medical practices and hospitals, forced upon healthcare providers through government mandates, new changes in coding procedures, and the peer pressure of keeping up with technological advancements. Clearly, a love-hate relationship exists with such an IT system that simultaneously creates an avenue for organizing and collecting large amounts of patient data, while imposing restrictions and additional workload and stress on physicians. But regardless of how one feels about the EHR, the technology is here to stay and the strategy for dealing with all its complexities is to embrace its assets and use it to your advantage to improve patient health and the health of your practice or organization. Here are a few suggestions on how to leverage good use of the EHR and turn it into a positive for you.
Change the negative mindset
The biggest concerns from healthcare providers about EHR use are the effects that it has on both patient and physicians. A recent study revealed that many physicians claim that it has a negative effect and interferes with the physician-patient relationship, with less time able to be spent on 1:1 interaction and more time eaten up by documentation on a computer screen during a patient visit. The end result? Decreased patient satisfaction and increase physician burnout from multitasking patient care and data entry duties.
However, like most technologies, there is a flip side to every coin. In the case of the EHR, collecting patient data into an accessible, central place enables better communication between physicians, and leads to a clearer understanding of a patient’s condition when EHR documentation is accurate and readable. This clarity in patient status can lead to better decision-making and in some cases, better interaction with patients when the physician is up-to-date with everything that has been going on during a patient’s care.
By focusing on improving the EHR system itself (i.e. through customizing EHR features to enhance workflow), and determining how it should be integrated and used in the day-to-day patient care workflow (i.e. use of skilled medical scribes to provide EHR documentation assistance), are important things to consider that can make the EHR transform from an inconvenient burden to potentially, your best friend.
The devil is in the details
Another key concern with EHR use is in the accuracy of data entry and, consequently, the safety of patient care. To safeguard against adverse consequences, several suggestions have been made to prevent faulty EHR usage. This includes establishing regular IT group meetings (similar to so-called clinical safety huddles) that will maintain vigilance with EHR issues that could potentially impact patient care. Additionally, improving the way in which data is formatted in the EHR can go a long way in transforming data into something clear and understandable to anyone that has access to it. Such tricks include paying attention to decimals (i.e. writing 0.5 instead of .5) to reduce potential errors in dosage, and using tall-man lettering for similarly-named drugs that are either entered into the system manually by the physician (or medical scribe) or developed as an automated technical feature in the EHR itself. Furthermore, highlighting abnormal laboratory results in a consistent way (i.e. labeling abnormal results in bold or red font) make it easier to flag issues that need to be urgently addressed.
Furthermore, the restrictions imposed on how data is entered into the EHR are, at times, hindering to physicians who are used to the free form description of patient events. EHR systems should be modified (i.e. customized through technical vendor support) to allow for both structure in basic clinical data entry and more flexibility for important descriptive details (i.e. text boxes that enable free text entry).
Avoid obvious errors
Errors in patient data are a physician’s worst nightmare and, unfortunately, these mistakes can happen from time to time. A study conducted by the University of California, San Francisco Medical Center found that 46% of text in an EHR were copied from previous notes, 36% were imported, and only 18% of text were entered manually by physicians. This is a cause for concern, since errors through copying and pasting text can introduce errors into the system and even carry over into multiple data entries.
To avoid such errors in documentation, physicians can enlist the help of medical scribes to relieve them of their clerical burdens. When the task of documenting patient events or visits is left in the hands of skilled, trained documenters that can accurately record information on the spot, the need for copying and pasting data is eliminated, along with the errors that follow from it.
It is important to understand the problems that arise from EHR usage, but also to recognize the advantages that EHR utilization can offer. In this way, one can make the most of EHR technology for your patient and your practice.