Keeping your office’s records accurate takes effort and careful planning.
While many EHR functions are routine and automated, human error is a very real possibility and may introduce unnecessary mistakes. In fact, one recent report published in the Journal of Medical Informatics and Record Keeping found that as many as half of all patient visits are not captured at all by EMR record-keeping. In some cases, even hospital visits were missing from patients’ records.¹
Knowing about common errors can help reduce the frequency of preventable mistakes and improve patient care. While a lack of interoperability can result in some missing information, many mistakes are caused by forgotten information, user error, system flaws, copy and paste mistakes, and other issues.
Random sampling of patient records
EHR errors arising from misinterpretations and template copying may be replicated on future records. Data copied to a new record should always be carefully reviewed for mistakes, but it is also important to have a system in place for reviewing a random sample of records on a regular basis. In fact, the Centers for Medicare and Medicaid Services (CMS) recommends choosing a sample of records for each type of insurance for random review using a checklist of accuracy measures. You may also want to review samples of each chiropractor’s records if your office has multiple doctors or randomly review each office assistant’s work. Even small practices should be able to check a few records every week or choose different sections to audit on a regular basis.²
CMS offers a brief guide with a printable jobaid chart for performing audits of your EHR records—this may help you develop your own plan. With your review methodology in place, you can begin conducting your own self-audits. Training your office staff to help with these audits may allow you to review more quickly, but do not forget to independently audit the work of all office employees.
Avoiding risky practices
Minimizing inaccuracy risks may require that you change some of EHR practices you use in your office. Copying and pasting, using templates and other time-saving techniques should be modified to reduce risk or eliminated altogether. For example, if copying is causing too many errors in your office, you may need to ban copying of certain types of notes or restrict copying to records for the same patient only.³ Records that contain a large amount of copied text could also be included in your ongoing self-audit.
If you use clinical decision support software, such as software designed to help you interpret test data, you should be aware of potential errors even when the program is working correctly. In fact, research suggests that many doctors who rely on these programs are likely to accept an incorrect interpretation provided by the computer.³
At this point, software is an imperfect substitute for physician judgment. It may be worthwhile to interpret test results independently or regularly audit the computer’s interpretations for accuracy.
As interoperability is still weak for some EHR systems, software that should readily “speak” to other offices’ EHR may malfunction and leave out key data. Being aware of this problem will help your office notice data gaps and missing information. When importing or sending records, be sure to check for these problems.
If you have questions about your EHR’s accuracy, you may need to ask your vendor about how you can improve your use of the software and prevent mistakes.
- Madden, J.M.; Lakoma, M.D.; Rusinak, D; Lu, C.Y.; Soumerai, S.B. “Missing clinical and behavioral health data in a large electronic health record (EHR) system.” http://jamia.oxfordjournals.org/content/early/2016/04/12/jamia.ocw021. Published April 2016. Accessed May 2016.
- Centers of Medicare & Medicaid Services. “Manual Review of Electronic Health Records.”https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-manual-review-jobaid.pdf. Published July 2015. Accessed May 2016.
- Bowman, S. “Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications.” Perspectives in Health Information Management. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3797550/. Published October 2013. Accessed May 2016.