In healthcare, the importance of good records hardly needs to be stressed. By documenting treatment, progress and outcomes accurately, patient records make effective health care possible and also help physicians justify services provided. The standard documentation process involves the physicians dictating notes and getting the audio recordings converted into text format by a professional medical transcription service company. With a reliable outsourcing vendor, physicians are ensured of accurate transcripts in customized turnaround time.
Electronic health record (EHR) implementation has changed the scenario to some extent, and with unanticipated consequences. According to a recent Healthcare IT News report, researchers have found that attending physicians tend to make more mistakes while using EHR than paper records. If they go undetected, such errors can have dire consequences for patients as well as for practitioners.
The study, which was published in the Journal of the American Medical Informatics Association (JAMIA), was based on an assessment of medical reporting at a Michigan hospital between August 2011 and July 2013. The review of 500 doctors’ progress notes in initial EHR implementation (some before and some after) revealed that they had more mistakes compared to paper charts. The key points and findings of the study are as follows:
- Progress notes evaluated included some before EHR implementation in 2012 and some after implementation
- The focus was on notes relating to five specific diagnoses with invariable physical findings: permanent atrial fibrillation, aortic stenosis, intubation, lower limb amputation and cerebrovascular accident with hemiparesis.
- The rate of inaccurate documentation in the EHRs was 24.4 percent which was significantly higher than the error rate of 4.4 percent in the paper charts.
- Overall, residents had fewer inaccuracies (5.3 percent v. 17.3 percent) and omissions (16.8 percent v. 33.9 percent) than attending physicians.
The researchers concluded that “further research is needed to identify training methods and incentives that can reduce inaccuracies in EHRs during initial implementation”.
Physicians are not trained to enter data into computerized systems. In fact, several studies have reported the difficulties they face with EHR data entry. This explains why medical transcription outsourcing remains a feasible option. It can help avoid EHR documentation errors. EHR-integrated medical transcription services allow doctors to get their dictations transcribed right into their electronic patient charts. This is made possible with custom document interface services for both standards-based (HL7) and proprietary systems. This automated system saves time and makes transcribed reports immediately available for review by the physician. Importantly, the reports are error-free as they are transcribed by professionals who are experts in the field.