The quality and utility of health information is what matters when it comes to providing timely and proper care. In fact, this is the underlying principle of medical transcription services. Using advanced technology and professional transcriptionists, outsourcing companies provide accurate, reliable, fast and secure documentation solutions for all medical specialties. Even with the electronic health record (EHR) mandate, many hospitals and practices continue to rely on these services to ensure comprehensiveness in medical records.
A new study published in the Journal of the American Medical Informatics Association has highlighted the limitations of EHRs in providing a complete picture of a patient’s health. According to the study, EHRs are fragmented and do not share patient information, with the result that the quality of care is affected. The researchers compared information available in a typical EHR with more inclusive data from insurance claims, with focus on diagnoses, visits, and hospital care for depression and bipolar disorder. The findings can be summarized as follows:
- The US health care system is fragmented, and lacks interoperability and information exchange among the hundreds of EHR systems currently in existence.
- This has resulted in incomplete information in most EHRs, as the digitized record cannot fully capture mental health diagnoses, visits, specialty care, hospitalizations, and medications. The missing data can result in medical errors and affect patient safety.
- Patients with depression and bipolar disorder averaged 8.4 and 14.0 days of outpatient behavioral care respectively, per year, and of these, 60% and 54% respectively, were missing from the EHR because they occurred offsite.
- Total outpatient care days were 20.5 for those with depression and 25.0 for those with bipolar disorder, with 45% and 46% missing, respectively, from the EHR.
- The EHR also did not report 89% of acute psychiatric services.
- For 27.3% and 27.7% of patients, study diagnoses were missing from the EHR’s structured event data.
The authors stress that while behavioral health care is unique, their findings show that the problem of incomplete clinical data in the EHR is not limited to behavioral care. Data was absent for overall events both in and outside the hospital. They also noted that specialist care of all types has a high risk of being underrepresented in a primary care EHR.
The study highlights the advantages of blending EHR-derived data with external sources of information.
Much has been said about the limitations of electronic medical records when it comes to ensuring the quality and completeness of clinical documentation. Physicians tend to adopt the short-cuts that the EMR software has, which might speed up documentation, but unfortunately, result in inappropriate use of copy/paste and templates. Dictation and medical transcription avoid this problem. Moreover, medical transcription services allow physicians to capture the patient narrative fully, translating into improved care as well as enhanced clinical documentation workflow.
