EHR systems: How to reduce risk in your practice

In the modern healthcare environment, electronic health records, or EHR systems, have become the gold standard for documentation.

Yet, some practices continue to rely on handwritten notes, a method fraught with significant challenges. Handwritten notes in a doctor’s office can lead to inefficiencies and potential risks that negatively impact patient care, legal compliance and operational effectiveness. EHR systems make data standardized, easy to read and accessible across multiple platforms, significantly reducing the risk of miscommunication.

Problems with handwritten notes

First and foremost, the legibility of handwritten notes is a major concern, and something that can be avoided using an EHR system. Illegible handwriting can cause misinterpretations among staff and other healthcare providers, potentially leading to incorrect diagnoses or improper treatments. Such mistakes jeopardize patient safety and can be serious.

Moreover, handwritten notes are inherently inefficient, leading to constantly falling behind in your notes and increasing the temptation to cut corners (compared to using an EHR system). Searching through physical files to find specific patient information is time-consuming and prone to error. This inefficiency can delay patient care and diminish overall productivity in the office. On the other hand, EHR systems allow for rapid retrieval of patient records, test results and treatment plans, enabling healthcare providers to deliver timely and accurate care.

Handwritten notes also lack the capacity for seamless integration with other healthcare providers. In today’s interconnected healthcare ecosystem, sharing data securely and accurately with specialists and lawyers is essential. EHR systems facilitate this integration, ensuring care continuity and streamlining provider communication. Handwritten notes, by contrast, create barriers to efficient collaboration and can result in incomplete or delayed information exchange. What’s equally bad is that when collaborating with MDs or working with lawyers, they will consider you a “dinosaur” and not part of the contemporary healthcare community, destroying your reputation and contributing to the erosion of chiropractic acceptance as a profession.

Questions of liability

From a legal standpoint, handwritten notes pose a significant liability risk. Inaccurate or incomplete documentation can be detrimental during audits or legal disputes, as it fails to meet the rigorous documentation standards expected in modern medicine. EHR systems offer features like time-stamping and audit trails, providing a clear and verifiable patient care record. EHRs are crucial in demonstrating compliance with regulatory requirements and protecting practices from potential lawsuits.

Meeting the Daubert Standard, a legal standard for admissibility, will be hard-pressed with handwritten notes to list methodology or references validating the necessity of care. They take too much time. Using a Word platform and cutting and pasting every time is better, but it is highly inefficient and will have you working through lunch, evenings and weekends.

Handwritten notes are also more vulnerable to loss or damage. Paper records can be destroyed by fire, water or other physical hazards, potentially leading to irretrievable loss of critical patient information. EHR systems, with their digital backups and secure cloud storage, mitigate this risk and ensure the longevity of records.

Additionally, handwritten notes lack the analytical capabilities EHR systems provide. Modern healthcare relies heavily on data analytics for decision-making, trend analysis and quality improvement. EHR systems can generate reports, identify patterns and support evidence-based practices, enabling providers to enhance patient outcomes. Handwritten notes, confined to static paper formats, cannot match this level of functionality.

Finally, patients increasingly expect their healthcare providers to embrace technology. The use of EHR systems in your practice signals a commitment to modern, efficient and high-quality care. Clinging to outdated practices like handwritten notes may erode patient trust and satisfaction.

Final thoughts on handwritten notes vs. EHR systems

In conclusion, handwritten notes should never be used in a doctor’s office due to their inherent limitations and risks. Transitioning to an EHR system enhances legibility, efficiency, integration, compliance and data security, ultimately improving patient care and operational success. By embracing EHRs, healthcare providers can meet the demands of contemporary medicine while ensuring the highest standards of care.

Mark Studin, DC, FPSC, FASBE(C), DAAPM, is an adjunct assistant professor at the University of Bridgeport, School of Chiropractic and an adjunct postdoctoral professor at Cleveland University-Kansas City, College of Chiropractic. He is a clinical instructor at The State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education. He earned his Fellowship in Primary Spine Care certified in joint providership from The State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Office of Continuing Medical Education, and Cleveland University-Kansas City, College of Chiropractic. He also runs the Academy of Chiropractic’s Personal Injury Program. He can be reached at 631-786-4253 or DrMark@AcademyOfChiropractic.com.