Sloppy EHR Data Signals Need for Standards

Joe Cantlupe, for HealthLeaders Media , February 21, 2013

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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3 comments on "Sloppy EHR Data Signals Need for Standards"

Reed D. Gelzer, MD, MPH (2/25/2013 at 3:51 PM)
Thank you for the summary article. It is odd that Ms. Dougherty apparently did not mention that extensive EHR System Standards already exist, as well as wide ranging Best Practices in Records Management. Ms. Dougherty was Chair or co-Chair of the Records Management and Evidentiary Support Profile Standard (RMES) Workgroup from its inception in 2004 thru 2011 and presided over RMES's publication as a Normative Standard in 2010, addressing most, if not all, of the gaps she correctly highlights in her comments. The problem, therefore, is not a lack of Standards, it is a lack of use of Standards by vendors, policymakers, and by clinical provider organizations. This is only one element of the current EHR System landscape that demonstrates how, to a great extent, the lack of data quality and information integrity support functions in EHRs has nothing to do with lack of systems capability or knowledge of what constitutes "fitness" in Records Management Systems. With this in mind, please consider a follow-on article to provide your readers with information correcting the impression given by your article that Standards pertinent to data quality and information integrity do not already exist, so that they may better understand the a number of important practical facts: 1. Standards and supporting due diligence tools exist to assure purchase, implementation, and use of EHRs supporting data quality and information integrity, as well as Billing Compliance and, 2. the damage being wrought by Federal subsidies for implementing systems that are not required to meet even the most basic fundamental requirements for a trustworthy electronic patient record, including data quality and information integrity. This would be a substantial and useful public service, as well as a proper credit to the HL7 Standards that Ms. Doughterty helped create, among the many hundreds of other HL7 Standards contributors. Reed D. Gelzer, MD, MPH Currently co-Chair of the HL7 Record Management and Evidentiary Support Workgroup.

Gus Geraci, MD (2/21/2013 at 4:07 PM)
Standards for use and storage would be lovely, for interoperability and many other reasons. The trick is to maintain or improve workflow and usability, many of which have been degraded by MU already. Beware the quest for improvement which degrades with many unintended consequences.

Robert Modugno MD MBA FACOG (2/21/2013 at 2:14 PM)
In their haste to bring EHRs to market both new and old school physicians are having teething problems. Most of their time is spent on data entry rather than on patient care. So far, most docs I know are uncomfortable with EHRs finding them cumbersome and time consuming and therefore they decrease productivity.Different systems don't talk to each other, thus quality medical care is compromised, tests are repeated, etc. The only "winners" are the insurance companies, the govt and the EHR companies. They are still not ready for prime-time IMHO. The doctors will end up taking "the blame" and the extra litigation. Robert Modugno MD MBA FACOG Marietta GA ( Recovering EHR user - three systems so far...)




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