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Would Use Of Technology Lead to More
Medical Record Errors?
EHRs are creating many unpredictable errors that may prove
costly in the long run. This may affect the quality of patient
care, patient safety and even medical record review for
litigation.
Any kind of transition is fraught with challenges in one form or
other. So why should EMR transition be any different? The
EMR transition has been made mandatory with the best interests
of patients, physicians and payers in mind but needless to say,
this passage is not at all smooth. The new digital technology is
bound to bring in more medical record errors or varying types of
medical record errors.
Doorways for Medical Record Errors
• Comprehensiveness of medical data transfer from paper to
electronic format: This is one area where errors or
shortcomings are likely to occur. Physicians and facilities
have voluminous patient data on paper and the question is
how much of the information to transfer. Healthcare
providers may use their own discretion to determine the
amount of data to be transferred and this may have a
negative impact in the long run.
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• Clarity of document scans: Medical document scanning is
the practical and easy way of digitizing paper records. The
clarity of the scans has an important role to play in ensuring
the accuracy of documentation. Moreover, errors already
present in the paper medical records may migrate to the
digital records and lead to further errors and ambiguity.
• The risk inherent in sharing medical records: The new
medical record system is being implemented with a view to
facilitate sharing of patient records and ensure coordinated
care. However, loopholes for serious errors exist. For
instance, if a mistake is made and goes unidentified, it will
create a wave effect and ultimately lead to very grave
issues. This is applicable for erratic entries for test results
and personal health details.
• Existence of duplicate records: The same patient may be
treated under different names by different providers. This
can be the case with a patient who is identified by her
maiden name with one provider and married name with
another provider.
• Errors caused by speech recognition software: Speech
recognition software is still developing and is prone to
errors. Mistakes are seen to occur in recognizing the
patient’s name, drugs, diagnoses and treatments provided.
An Example in Hand – Faulty EHR Systems in
Emergency Departments
ModernHealthcare.com highlights a report that refers to the
serious concerns posed by electronic health record systems. The
report is by two emergency physicians’ study groups that found
that EHR systems used in EDs are so weighed down by poor
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data displays, and plagued by numerous alerts warning of
potential patient safety issues that they can ultimately lead to
user alert fatigue and may even generate wrong physician
orders. Healthcare providers on their part are mostly confused
with no required information that could help fix the issues. Quite
alarmingly enough, a number of clinical practitioners are
reporting a considerable increase in the number of wrong
patient/wrong order errors when using the computerized
physician order entry component of these systems. This speaks
volumes of the need to expedite EHR monitoring in emergency
departments to ensure that patient safety and care are not
compromised. In fact, many scholarly journals including the
New England Journal of Medicine have already published
articles emphasizing the presence of actual risks when using
electronic health records and other forms of health information
technology.
The gravity of the problem lies in the fact that system
functionality varies a great deal for the EHRs used in emergency
departments, whether these are designed in-house, commercial
systems made specifically for EDs or are part of
multidepartment, multifunctional, commercial “enterprise”
EHRs. The inconsistency has a negative impact on physician
workflow, communication, decision making and thereby affects
patient safety and the quality of care provided. Experts point out
the need for EHR vendors to consider the seriousness of the
situation and develop foolproof products instead of having
clinicians tussle with complex electronic systems.
Medical Record Review amidst This Uncertainty
So how does medical record review for legal and medical
purposes fare amidst all this confusion? Undoubtedly, medical
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litigators will have a tough time reviewing the medical
documentation especially if there are intentional or inadvertent
errors carried from one system to another. You can’t rule out the
fact that use of technology, especially technology that is not
perfected yet, may hinder smooth medical record review for
litigation purposes. Any erroneous documentation can lead to a
wrong view of the case and consequent wrong decision making.
Now it has become more important for lawyers to rely on
professional medical review services to ensure more accurate
medical reviews and clear understanding of a case. Though it
may not solve the problems in their entirety, experienced
reviewers will be able to identify possible errors and
discrepancies in the medical reports. Being trained in medical
terminology and with a good awareness of medical procedures
and treatments, they will more easily spot out issues including
wrong drug names, possibilities of wrong/missed diagnoses and
other such issues.
The possibility of technology leading to more medical errors is a
frightening prospect indeed. However, EMR transition is
necessary and it is the onus of electronic health record
developers to devise systems that will improve clinician and
facility efficiency and help meet the healthcare goals set by the
federal government.
Posted by MOS Medical Record Review Company
http://www.mosmedicalrecordreview.com/
http://www.mosmedicalrecordreview.com/ 1­800­670­2809