Most healthcare providers, patients, and industry stakeholders agree EHR technology has the potential to yield marked improvements in population health management, predictive medicine, and clinical decision-making. However, EHR use also introduces new risks to patient safety. A study released in October of 2017 found EHR use has been listed as a contributing factor to patient injury at an increased rate over the past decade. Poorly-designed EHR systems combined with human error have resulted in patient safety problems in an increasing number of malpractice claims from 2007-2016. Here are a few steps providers and IT developers can take to deter this rising trend.
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Limit use of copy-paste functionality
Shortcuts built into EHR systems have been embraced by provideders as a way to reduce the amount of time spent at their monitors. However, one shortcut could potentially pose a threat to patient safety.
Researchers in a 2017 JAMA study found providers may be increasing the risk of patient harm by entering repetitive or inaccurate EHR clinical data into physician notes using copy-paste functionalities.
Ultimately, researchers found resident physicians used copy-paste to enter more than half of all data into physician EHR notes. The prevalence of copied information in physician notes increases the likelihood of repetitive, nonspecific, and irrelevant data existing in EHRs.
“Copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error,” researchers stated.
Researchers recommended healthcare organizations and health IT developers consider ways to limit the amount of copied information in physician EHR notes by inhibiting certain information from being saved.
“This finding could spur EHR design that makes copied and imported information readily visible to clinicians as they are writing a note but, ultimately, does not store that information in the note,” researchers stated.
The National Institute of Standards and Technology (NIST) also cautioned providers against relying too heavily on the copy-paste functionality for clinical documentation.
Along with the ECRI Institute and U.S Army Medical Research and Material Command’s (MRMC) Telemedicine and Advanced Technology Research Center (TATRC), NIST offered recommendations for reducing copy-paste-related errors.
Specifically, researchers recommended implementing EHR designs that enhance the visibility of information being selected for copy and paste to prevent users from inadvertently copying certain unrelated or unwanted areas of information.
Additionally, authors recommended locking certain areas or sources of information to prevent copying altogether. For example, organizations could disable the copy-paste function when providers are entering data into a blood bank information system to prevent errors related to blood transfusions.
Limiting or restricting over-use of the copy-paste functionality during clinical documentation can help to reduce patient safety threats stemming from irrelevant or redundant information.
IMPLEMENT A SIMPLE, UNCLUTTERED EHR INTERFACE
Simple EHR interfaces are best, according to a recent report from Pew Charitable Trusts.
Convoluted or overly-complex EHR designs can confuse providers and negatively impact clinical productivity. Poorly-designed EHR interfaces can also inhibit providers’ ability to quickly find information.
Furthermore, EHR interfaces that lack key information altogether can cause clinicians to search for data in multiple places, which may slow down patient care delivery.
“Important design principles include knowing what users need for a simple interface, removing complexity, using simple and clear terminology, emphasizing key elements, and using color effectively to draw users to important areas,” advised the authors.
By extension, healthcare organizations should also refrain from excessive EHR customization.
“These customizations — which may be requested by a health care facility or staff — may not have undergone rigorous testing by the care team or the product developer to detect potential safety concerns,” the research team wrote.
Keeping EHR design simple improves EHR usability and enables providers to view information in as clear, concise, and straightforward a manner as possible. Ensuring EHR data is clear and accessible can help to reduce the chances of clinical errors and EHR-related safety risks.
IMPROVE PHYSICIAN EDUCATION SURROUNDING EHR USE
EHR system design can play a hand in heightening the risk of patient safety problems, but human error is more commonly the culprit.
Reducing safety risks related to human error require improved physician education about EHR technology and use. At the 2017 ONC Annual Meeting, a panel led by ONC Chief Medical Officer (CMO) Andy Gettinger discussed the importance of understanding how EHR software works.
In an effort to increase provider understanding of EHR technology, ONC is working to develop a “Usability Change Package” focused on building a tool provider organizations can use to gain a base level of knowledge about usability.
The resource will provide informational materials to EHR users in a variety of settings to help them assess and improve the usability of their systems.
“Now with ONC and this change package work, we’re seeing much more attention around implementation and what is happening there,” stated Raj Ratwani, National Center for Human Factors in Healthcare Senior Research Scientist and Scientific Director.
Educating providers about the affect implementation decisions can have on the overall usability of their EHR systems can help to avoid costly, long-term software problems.
ENCOURAGE HEALTH IT DEVELOPERS TO IMPROVE HEALTH IT STANDARDIZATION
While healthcare organizations bear responsibility for EHR use-related errors, health IT developers and certification bodies can also help to reduce liability risks.
“We became aware of the potential liability risks related to the use of EHRs shortly after their introduction, and we anticipated that EHRs would become a contributing factor to medical professional liability claims,” wrote authors in a 2017 report from the Doctors Company.
Researchers suggested most EHR-related problems could be attributed to a lack of widespread standardization among health IT developers early on after EHR adoption became common.
“Many EHR-related problems could have been avoided if the federal government had developed vendor standards for EHR use and interoperability and required beta testing in the healthcare environment to ensure usability and safety before the HITECH Act mandated its widespread adoption in 2009,”they wrote.
Improving standardization and usability testing could help to reduce or avoid EHR-related patient safety risks. Additionally, researchers suggested health IT developers take provider concerns and other feedback into account when designing EHR technology in the future.
“Physicians and other healthcare workers played a minimal role in the initial design of the EHR, and their concerns have been largely ignored,” stated researchers.
Improved communication between health IT developers and providers could serve as a way to reduce provider frustrations with EHR use and limit patient safety risks through more streamlined, standardized system design.
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing, Medical Transcription, Scribe Services, and AzaleaHealth EHR. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists. #MedicalTranscription #AzaleaHealthEHR #RevenueCycleManagement #MDSofKansas #MedicalBillingService #MedicalScribes
A new survey from SelectHub, a technology selection management company, examined the thoughts of medical professionals and patients regarding electronic health records.
The team interviewed 1,007 Americans who have access to EHRs, as well as 107 healthcare professionals, including nurses, physician assistants, administrators, technicians and medical laboratory scientists. In an email, Chris Lewis, a creative partner of SelectHub, said the survey results were not limited to users of a certain EHR vendor or system.
Apparently, healthcare workers and patients both have a fairly positive sentiment of EHRs — at least according to the survey.
Among healthcare professionals, 53.5 percent said they had a positive outlook on EHRs, and 33.7 percent indicated they had a very positive stance. Approximately 10.9 percent had a neutral opinion, 2 percent expressed a negative opinion and 0 percent had a very negative outlook.
These results are surprising, given that electronic health records are often considered something healthcare workers love to hate.
Despite these favorable viewpoints, EHRs don’t seem to be cutting down on the amount of time professionals spend on health records. Among those who switched to using an EHR system, the average number of hours per week spent on health record work only decreased from 19.7 hours to 18.6 hours.
Additionally, 81 percent of professionals said EHRs have increased general workplace productivity.
The SelectHub survey included a wide range of healthcare participants, such as administrators, medical laboratory scientists and office receptionists. But it is interesting to note that a study out of the University of Wisconsin and the American Medical Association found that at least among primary care physicians, EHRs are time-consuming and only complicate matters. According to that study, EHR-related tasks take up nearly half of the average PCP’s workday.
Among patients included in the SelectHub survey, 60.4 percent expressed a generally positive opinion of EHRs, and 19.7 percent had a very positive opinion. Additionally, 16.6 percent had a neutral stance, 3 percent had a negative opinion and 0.3 percent indicated a very negative opinion.
“Perhaps the most surprising aspect of our research though was the reasoning behind patients’ support of EHR technologies,” Lewis said via email.
Seventy-six percent of patients said they believe their doctor’s use of an EHR has either a positive or very positive impact on the healthcare they receive.
“Furthermore, those who received thorough instructions on EHR use and access reported accessing their records more than twice as frequently, suggesting a potential need for more information resources for patients,” Lewis added.
Photo: Mutlu Kurtbas, Getty Images
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing, Medical Transcription, Scribe Services, and AzaleaHealth EHR. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists. #MedicalTranscription #AzaleaHealthEHR #RevenueCycleManagement #MDSofKansas #MedicalBillingService #MedicalScribes
ORANGE, Calif., August 24, 2017. The American College of Medical Scribe Specialists (ACMSS) applauds the passage last Friday of a bipartisan bill in the U.S. House of Representatives to create a pilot study in Veteran’s Administration hospitals to determine whether using Medical Scribes to assist physicians will help shorten the VA’s notoriously long wait times and ease other patient service problems. ACMSS only asks that the Senate modify the language in the bill to ensure the VA employs only Certified Medical Scribe Specialists.
The purpose of The Veterans Affairs Medical Scribe Pilot Act of 2017 (HR 1848), introduced by Rep. Phil Roe, M.D. (R-Tenn.), is to create a two-year medical scribe pilot program under which VA will increase the use of medical scribes at ten VA medical centers, employing 30 scribes in all. It is hoped that the use of medical scribes in the program will reduce the amount of time physicians spend on daily documentation so that they may increase the number of patients physicians can see and the amount of time physicians are spending with each patient. Every 180 days during the two-year program the VA will be required to report to Congress the programs effect’s on provider satisfaction, provider productivity, patient satisfaction, average wait time and the number of patients seen per day.
After the bill’s passage, Roe, who is Chairman of the House Committee on Veterans’ Affairs and a physician, released a statement on the purpose of the legislation. “Since the VA waitlist scandal broke three years ago, I’ve examined several ways to improve patient care for veterans, and one that came up repeatedly in discussions was cutting down on the time physicians spend entering data,” Roe said. “Many private-sector physicians report the use of medical scribes has a positive and meaningful impact on their ability to see patients. Scribes can help input patient data and allow physicians to focus on patient care and use their time more efficiently. That’s why I introduced legislation to start a pilot program to examine whether or not the use of medical scribes would have similar positive effects in the VA.”
ACMSS agrees with all of the elements contained in the Act, but is sending a letter to the Senate Committee on Veterans Affairs, asking for one change before the bill goes to the Senate for a vote. “If this legislation is approved in the Senate and the program goes forward, employing Medical Scribes to assist physicians at the VA will undoubtedly improve efficiencies and have the positive effect the bill proponents desire, and more,” said ACMSS Executive Director Kristin Hagen. “However, in approving the language, ACMSS urges the Senate to insist that only Certified Medical Scribe Specialists be used in the program. Medical scribes provide real-time documentation and increase practice efficiencies in a great number of areas outside of clinical documentation, but they must be certified.”
ACMSS is an independent certifying organization and works in compliance with the Centers for Medicare and Medicaid Services (CMS) to meet national goals and initiatives of Meaningful Use of Certified Electronic Health Record Technology (CEHRT), and Medicare Access and CHIP Reauthorization Act (MACRA) and its Merit-Based Payment Incentive System (MIPS). Certified Medical Scribe Specialists also meet the “qualified people” standard in CEHRT and assist with the design and infrastructure to support ongoing transformative care and change.
The ACMSS certification program meets current and proposed CMS certification requirements toward use of EHRs through its Medical Scribe Certification & Aptitude Test (MSCAT). In addition to the overall certification exam, ACMSS provides specialty certifications in vascular medicine, dermatology, oncology, primary care, internal medicine, emergency medicine and general patient care, enabling access to all across the specialties.
“Employing Certified Medical Scribe Specialists is the best way that care providers get can ensure they get back the time and attention they need to join the evolution of the outpatient healthcare industry into a patient-centered system that focuses on integrative medicine, prevention, disease reversal and wellness,” Hagen said.
Please contact ACMSS directly at info@theacmss.org, visit our website at theacmss.org, or phone 800-987-3692 if you have any questions regarding the ACMSS program and/or materials.
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing, Medical Transcription, Scribe Services, and AzaleaHealth EHR. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists. #MedicalTranscription #AzaleaHealthEHR #RevenueCycleManagement #MDSofKansas #MedicalBillingService #MedicalScribes
As we get ready for National MT week, let’s take a look at the importance [still] of the Medical Transcriptionist in today’s healthcare industry:
A skilled workforce produces quality documentation. Healthcare documentation specialists (HDSs) and medical transcriptionists (MTs) ease the documentation burden from physicians.
HDSs and MTs consistently achieve documentation accuracy rates higher than 99%,¹ and by harnessing this workforce’s expertise, clinicians’ time, coding, and revenue are optimized and the data governance strategy is strengthened.
The narrative allows physicians the opportunity to add the qualitative information that provides context to the patient’s medical history and care. HDSs and MTs understand the complex story-telling of patient care and are experts in document standards and data capture.
Your healthcare documentation team are highly skilled, analytical quality assurance specialists who provide risk management support in capturing healthcare encounters and making sure they are documented in a way that promotes clinical clarity and coordinated care.
HDSs and MTs need to be positioned to ensure accurate documentation of care encounters and to identify gaps, errors, and inconsistencies in the record that may compromise care or compliance goals.
HDSs’ and MTs’ body of knowledge is vast and includes pharmacology, human disease processes, anatomy and physiology, HIPAA, privacy and security, and diverse technologies used to capture health data.
Certify to healthcare delivery that HDSs and MTs have the training and expertise to be valued among the allied health and HIM delivery teams by earning and maintaining your professional certification.
#NMTW #PrecisionMatters
Medical Document Services of Kansas, LLC (MDS) is a Wichita, Kansas healthcare document service specializing in Medical Billing, Medical Transcription, Scribe Services, and AzaleaHealth EHR. We provide efficient, accurate, affordable quality services for hospitals, clinics, and facilities of all sizes. Call 866-777-7264 today, or visit our website for more information. We have education programs in Medical Scribe Specialists. #MedicalTranscription #AzaleaHealthEHR #RevenueCycleManagement #MDSofKansas #MedicalBillingService #MedicalScribes
