Laboratory testing plays a crucial role in both health assessment and health care. The test results are used in the diagnosis and prognosis of disease, monitoring treatment and patient’s health status and population screening for disease. Accurate documentation of laboratory test results is therefore very important for effective diagnosis and safe and successful treatment. Though Electronic Health Records (EHRs) ensure quick availability of laboratory test results, especially while managing ambulatory patients, the quality of electronic documentation (EHR-generated graphs) is at stake as per a study published in the Journal of the American Medical Informatics Association. Let’s take a look into this and see the importance of an integrated approach involving EHR and medical transcription.
The study revealed the significant limitations with the graphical display of laboratory test results within EHR and found that the test results are often displayed in non-standardized manner. The researchers evaluated the graphs of lab results in eight records from three EHR systems. They used 11 criteria including titles, legends, and x- and y-axis labels for evaluation and obtained subpar results. None of the three systems met all 11 criteria and only three met five criteria. The major findings of the study are as follows:
- One criterion (having a graph with y-axis labels that display the name of the measured variable and the units of measure) was missing from all the three EHRs
- The graphed results of one EHR system was in reverse chronological order
- One of the EHR systems plotted data at unequally spaced points in time
- All of the three systems didn’t display the identifying information of the patients directly on the graph
According to the researchers, suboptimal graphical display of test results can seriously impact clinical decision-making. It is possible to extract very crucial diagnostic clues like downward hemoglobin trends from EHR-generated graphs. The above mentioned limitations in graphic capabilities of laboratory test results have a significant, negative impact on patient safety. Accurate display and interpretation of test results is necessary to ensure patient safety. The researchers recommend policymakers to ensure clear and accurate visual display of laboratory data.
In short, the study implies EHR documentation of laboratory data can be really helpful for effective diagnosis and treatment only if it is displayed and interpreted in an accurate and standardized manner. To enhance accuracy, you can manually enter the laboratory data into the EHR. This is a hectic task and bears the risk of copy-pasting errors as well as limited narrative description owing to templates. The combined use of EHR and medical transcription is thus a significant approach. In this integrated approach, all the recordings are transcribed in a standardized manner with the help of transcriptionists and the transcribed data is populated into EHR fields through advanced transcription technology. This will help improve the accuracy of electronic reports.