EHR Interoperability and Detailed Clinical Documentation Needed to Improve Patient Care

EHRIt’s no secret that, even with the advent of electronic health records (EHRs), detailed documentation as provided by a medical transcription company enhances patient care. Medical transcriptionists ensure that accurate information is entered into the EHR and also that the digital record captures more details about the patient encounter than that allowed by the rigid EHR template.

A recent article in Medical Economics adds an important dimension to the treatment scenario – EHR interoperability. According to the author, a physician, obtaining data from a prior hospital stay of the patient can improve care delivery by helping in the medical decision-making process. She discusses the case of a patient referred to her who suddenly fell ill on his visit to New York City. He had been previously hospitalized in another state but could not provide much information on this. The doctor could not get timely access to the details of his recent hospitalization and EHR which she says, would have been helpful in reducing the length of stay and avoiding unnecessary tests.

The aim of the U.S. Department of Health and Human Services is to make interoperability between disparate EHRs a common capability by 2024. However, industry experts point out that there are many challenges to achieving the goal of seamless sharing of patient information among authorized practitioners. Here are the key factors that make EHR interoperability a challenge:

  • Lack of proper standards for exchanging information electronically
  • Varying privacy rules among states regarding exchange medical records across their borders
  • Technical differences among systems make it difficult to create one standard format for sharing data
  • Providers are discouraged by the extremely high data exchange fees

While linking the vast amount of data sources that are important to patient outcomes and care management is quite complex, it is a desirable goal to save time and to coordinate care efforts across the entire health care system.

At the same time, the information in electronic health records needs to be comprehensive and include all the details on the patient’s health status. At present, medical transcription services go a long way in making such information available. The patient’s digital record should include data on primary care and hospital visits, insurance and payment, patient history, medication details, patient and family health history, clinical trialand so on. The goals and full potential of EHR interoperability can be realized only if all this data can be easily accessed by both providers and patients.

Julie Clements

About Julie Clements

Joined the MOS team in March of 2008. Julie Clements has background in the healthcare staffing arena; as well as 6 years as Director of Sales and Marketing at a 4 star resort. Julie was instrumental in the creation of the medical record review division (and new web site); and has especially grown this division along with data conversion of all kinds.