The adoption of Electronic Health Record (EHR) has significantly increased in recent years, with most hospitals and office-based physicians now utilizing them. In 2021, 88.2% of U.S. office-based physicians had adopted EHRs, and 77.8% were using certified systems, according to the CDC. However, while EHRs have improved data exchange and care coordination, they have also significantly increased the clinical documentation burden for providers. Multiple studies have also shown that errors in entering information into patient records are both common and persistent. This is where EHR-integrated medical transcription services play a vital role. Outsourcing voice-to-text conversion to a company that combines human expertise with advanced technology ensures accurate, efficient documentation—minimizing risk of errors, reducing workload, and allowing clinicians focus on patient care.
This posts explores the impact of EHR data entry errors on clinical documentation quality and how outsourcing medical transcription provide the solution.
Documentation Errors in EHRs: A Costly Challenge
Accurate data capture is critical to EHR data integrity. However, multiple studies have shown that errors in entering information into patient records are both common and persistent. These errors can happen when:
- Incorrect information is entered
- Correct information is placed in the wrong field, or s
- System alerts for interactions or contraindications are overlooked
Human mistakes, technical issues, or lack of standardization in data entry practices can lead to EHR data entry errors, posing risks to clinical documentation accuracy, patient safety, and legal compliance.
Here’s what makes EHR documentation errors a costly challenge:
- Causes Physician Burnout and impacts Data Quality
EHR data entry takes up physicians’ valuable time. According to research published by JAMA Network in 2023, providers may be spending more time interacting with EHRs than with their patients. On average, they spend over 36 minutes working in the EHR for every 30-minute patient encounter, highlighting the growing administrative burden placed on clinicians.
Physician burnout is strongly linked to an increase in documentation errors, which can negatively impact patient safety and outcomes. Burnout can lead to cognitive fatigue, making it harder for physicians to focus on complex tasks like accurate documentation, according to research from the National Institutes of Health (NIH).
- Compromises Patient Safety
EHR data entry errors can significantly compromise patient safety. These errors, whether due to manual entry mistakes, system design flaws, or information overload, can lead to inaccurate patient information and ID errors, misdiagnoses, incorrect treatments, and medication errors, and ultimately, patient harm.
- Claim Denials and Audits
Typos or inaccurate data entry in critical fields within the EHR system can directly lead to claim denials and audits, impacting revenue cycle management and potentially lead to penalties. Incomplete, inaccurate, or outdated documentation can cause claims to be rejected or denied by payers, necessitating time-consuming corrections and appeals.
- Increases Malpractice Risks
A wide-ranging 2020 report, Malpractice Claims Report: EHR Documentation Errors Still Far Too Common analyzed data from nearly 12,000 events pertaining to more than 20,000 closed claims across a 10-year period from 2010 to 2019. The study found that average indemnity paid for physicians’ medical malpractice claims increased 20 percent during the study period, to $411,053. According to the study, documentation accounts for the majority of EHR-related risk issues, representing 72% of reported cases. The researchers noted that the risks typically occur when users:
- select the wrong dropdown
- view the wrong screen
- enter outdated information, or
- mistakenly document in the wrong patient’s chart
Other common sources of risk include system-related problems such as poor interface design, indiscriminate use of the copy-paste function, errors introduced during system conversions, lack of EHR training and education, health records in multiple formats and stored in several locations, and overall challenges with EHR usability.
Medical Transcription Services for Accurate Clinical Documentation
Professional medical transcription services is an effective way to reduce EHR errors
- 1. Accurate and Complete Documentation
Medical transcriptionists are trained to listen carefully to dictations and convert spoken words into well-structured, accurate clinical documentation. Unlike hurried typing during patient visits, transcription allows for thoughtful and complete records, reducing the chances of mis-entered data or missing information.
- 2. Reduction in Data Entry Mistakes
EHR errors often occur when providers manually enter data under time pressure, leading to wrong fields, wrong patients, or overlooked warnings. Transcription services eliminate the need for real-time typing by the clinician, minimizing these manual errors and ensuring that information is properly categorized and contextually accurate.
- 3. Improved EHR Usability
Experienced transcriptionists deliver clean, structured documentation that integrates seamlessly with EHR systems. This improves readability, searchability, and usability, helping providers make better clinical decisions without sifting through cluttered or inconsistent notes.
- 4. Consistent Terminology and Formatting
Transcriptionists follow standardized medical language and formatting rules, ensuring uniformity across patient records. This consistency is essential for effective communication among healthcare teams and reduces errors related to unclear or ambiguous entries.
- 5. Lowered Cognitive and Administrative Burden
By outsourcing voice-to-text conversion, physicians can focus on patient interaction instead of navigating complex EHR interfaces during consultations. This reduces stress, lowers the risk of burnout-related errors, and allows for more accurate documentation after the visit, when details are still fresh.
- 6. Quality Checks and Human Oversight
Unlike speech recognition software alone, transcription services include human review, which helps catch contextual inaccuracies, dictation errors, or system misinterpretations—common causes of EHR discrepancies.
Expanding Role of Generative AI in Clinical Documentation
Generative AI is rapidly advancing to help close documentation gaps in EHR systems. Driven by the rise of chatbot interfaces like ChatGPT, health IT vendors and healthcare systems are increasingly piloting generative AI tools to streamline clinical documentation. According to a recent HLTH report, healthcare AI startup WorkDone has developed an AI-powered compliance co-pilot that integrates directly with hospital EHRs using standards like HL7, FHIR, and other industry protocols. This tool monitors clinical workflows in real time to identify and address issues such as missing discharge summaries or incorrect medication timing.
However, while these technologies show promise in reducing the documentation burden linked to clinician burnout, several challenges still stand in the way of broad adoption.
Tech Target reported on a study of 10,000 physicians and staff at The Permanente Medical Group that assessed the adoption of ambient AI scribes. Physicians reported that ambient AI improved the quality of patient conversations. Providers experienced reduced after-hours EHR documentation workload.
However, providers must review all AI-generated documentation drafts to ensure accuracy and maintain patient safety. The report noted that a 2023 study found that ambient AI struggles to capture non-lexical conversational sounds (NLCSes), such as “mm-hm” or “uh-uh,” which often carry clinical significance. Critical error rates were:
- Overall word error rate: ~12%.
- NLCS word error rate: 40%–57%.
- For clinically meaningful NLCSes, the error rate soared to 94.7%–98.7%.
“Implementation will require improvements in accuracy, completeness and safety,” the authors wrote. “Given the safety concerns, initial implementation will require physician review.”(TechTarget).
Enhance EHR Documentation: Outsource Medical Transcription to Experts
Outsourcing the voice-to-text conversion process to a medical transcription company that integrates human transcription skills and the latest technologies ensures that patient information is captured accurately and efficiently. Partnering with experts not only improves documentation quality but also reduces administrative workload, allowing clinicians to focus more on patient care.
