Regardless of the illness or healthcare setting, patient records that medical transcription companies help physicians document contain similar information such as the chief complaint or reason for the visit, history and physical or assessment and plan, progress notes, test results, and orders. Certain medical specialties and settings have requirements that are exclusive to their fields.
According to recent reports, the COVID-19 pandemic calls for a new kind of electronic health record (EHR) that can better meet patient needs. The main problems with EHRs that are confusing physicians include:
- User interfaces and usability issues
- Overloading of information
- Quality of the data entered
- Limited ability of the data to support discovery and interoperability among systems
- Limitations in supporting complex clinical care
- Do not support clinicians’ dynamic needs
- Inability to exchange information
The large amounts of data EHRs contain can overpower clinicians and negatively impact efficiency as providers spend time searching through large quantities of clinical data to find the specific information they need. With information overload, clinicians have a tough time determining what data is important and what is the right treatment and prevention plan for each patient, notes Harvard Business Review (HBR). This has become especially challenging in the context of COVID-19. Modifying EHR design to reduce the amount of time providers spend searching through EHRs for specific data, and interacting with EHR systems can help to boost clinical efficiency and reduce provider dissatisfaction with EHR technology.
According to the American Medical Association, EHRs should be designed and configured to:
- Improve physicians’ ability to provide high-quality patient care
- Support team-based care
- Promote care coordination
- Offer product modularity and configurability
- Minimize cognitive workload
- Help data liquidity
- Allow for digital and mobile patient engagement
- Expedite user input into product design and post-implementation feedback
HBR is optimistic that the experiences of leading EHR vendors will pave the way for a new kind of EHR that can not only track what happened to the patient, but also help clinicians plan for the patient’s health and deliver information to the physician and patient. Such as plan-focused EHR would be better equipped to deal with outbreaks like Covid-19 by:
- Ensuring that each patient’s care plan incorporates the latest evidence-based treatments based on their current status and underlying health conditions
- Providing data of each patient’s response so that the plan for the next patient can be improved.
EHRs with these capabilities could dramatically improve outcomes and reduce fatalities.
HBR lists the features of a plan-centric EHR as follows:
- A library of care plans for different situations: Plans would differ among patients depending on their individual circumstances, medical conditions and how well they are managed, and preferences.
- Combination of appropriate algorithms to form a patient’s master plan. Patients may have more than one medical condition and a master plan should combine appropriate algorithms for treating these different conditions.
- Support for the care team. The master plan can be viewed by the patient and all professionals involved in a patient’s care such as the primary care physician, specialists, nurse practitioners, pharmacists, and case managers. Each team member would have their own to-do list and would be able to assign tasks to one another.
- Interoperability: The plan must travel seamlessly with the patient. It will be able to navigate care settings, geographical areas and different EHRs. With interoperable systems, providers can integrate a patient’s plan regardless of where it was created.
- Decision support and workflow logic. The system would alert team members of upcoming and overdue activities, suggest changes in the plan based on the changing care needs of the patient, and informed the concerned team member about new test results or patient events.
- Analytics for both individual patients and populations. The system must be able to evaluate the plan’s progress towards its goals, both for the individual patient and for the larger population under the provider’s care. The experiences of treating one patient can then be applied to other patients.
As EHR technology advances to better meet clinician and patient needs, medical transcription services will continue to be relevant to ensure accurate and timely documentation in the system.