Documentation matters: EHRs can help improve diagnostics and outcomes

According to marketing chatter, electronic health records (EHR) software systems can improve everything from how patients come into and out of your office, to diagnostics and patient outcomes.

It is tempting to consider EHRs the shiny, new thing and move on; however, beneath all of the hype, there are some important positive factors to consider. In fact, diagnostics and patient care do tend to be improved in offices where these systems are used.

Diagnostics

How can a patient record of any kind contribute to knowing what is wrong and how to fix it? It comes down to documentation. One of the newer problems professionals, particularly in the field of healthcare, face is that too much information is available¹—and with an EHR, that information can be filtered. Finding and accessing exactly what you are looking for electronically is far easier than searching through reams of paper records.

Another big diagnostic advantage is that caregivers can see and share information. You have access to other perspectives, which can be powerful. For example, if you have a patient with osteoarthritis of the knee, you can see what the rheumatologist has recommended or what happened during a physical therapy appointment. An EHR can “facilitate the documentation of evolving history and ongoing assessment. Rather than requiring a record to start from scratch with each new physician or encounter, electronic notes should follow an evolutionary paradigm.”¹

A caveat

In order for the diagnostic improvements associated with EHRs to be garnered, practitioners must do their part. Rather than simply using a template, make specific notes about each visit, including any changes since the previous visit.²

Patient outcomes

The end goal of any treatment is for improvement—a better patient outcome. It may seem like a stretch of the imagination to think patients could be better off due to how records are kept in a chiropractic practice, but there is some evidence showing that is the case.

According to HealthIT, EHRs can reduce errors, improve safety, and support better outcomes:³

A qualified EHR not only keeps a record of a patient’s medications or allergies, it also automatically checks for problems whenever a new medication is prescribed and alerts the clinician to potential conflicts.
Information gathered by a primary care provider and recorded in an EHR tells a clinician in the emergency department about a patient’s life-threatening allergy, and emergency staff can adjust care appropriately, even if the patient is unconscious.
EHRs can expose potential safety problems when they occur, helping providers avoid more serious consequences for patients and leading to better patient outcomes.
EHRs can help providers quickly and systematically identify and correct operational problems. In a paper-based setting, identifying such problems is much more difficult, and correcting them can take years.

Although the upfront expense in both time and money may seem onerous, if an EHR system can bring about better diagnostics and outcomes for patients—not to mention the many other possible improvements to how your office functions—then it will quickly offer a return on your investment.

References

¹ Bates D, Schiff G. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010;362(12):1066–1069.

² Schetchikova N. “Documentation with EHR-easier, faster, better? Part II.” ACAToday.org. http://www.acatoday.org/content_css.cfm?CID=4279. Accessed May 2015.

³ HealthIT. “Improved Diagnostics & Patient Outcomes.” HealthIT.gov. http://www.healthit.gov/providers-professionals/improved-diagnostics-patient-outcomes. Updated March 2014. Accessed May 2015.