As a medical transcription company, we provide electronic health record (EHR) centred documentation solutions for various specialties including pediatrics. The implementation of EHRs in pediatrics offers many benefits. In fact, a recent press release from the American Academy of Pediatrics highlights the provisions of the 21st Century Cures Act which was passed in December 2016, that focus on the development, adoption and use of health information technology (IT) in medical care. The legislation recognizes that children have special health care needs, including needs related to health IT. The law directs the secretary of the U.S. Department of Health and Human Services (HHS) to recommend and implement voluntary certification criteria for health IT used to support the care of children.
According to Christoph U. Lehmann, M.D., FACMI, FAAP, the medical director of the AAP Child Health Informatics Center (CHIC), “Certification of electronic health records (EHRs) in pediatrics will result in safer, higher quality care for children and better workflow for pediatricians.”
Pediatricians need to ensure that the medical record faithfully documents the child’s condition and the physician’s plans. This is crucial to record the presence/absence of diagnostic signs or atypical events that point to serious illness. A Public Health Law Map report notes that pediatric record keeping involves certain specific issues:
First, most visits are for minor illnesses and consequently, many physicians tend to keep only sketchy records on children.
Second, unlike adult medical records, pediatric medical records need to track growth and development.
Other special considerations in pediatrics include complex privacy and confidentiality considerations, and the dynamic developmental needs of children and adolescents.
Besides improving the quality of patient care and providing easy access of data, EHR implementation helps physicians detect disease quickly, improve surveillance, and make quality comparisons. Today, advanced software allows pediatricians to:
- Track patients’ growth data by calculating, comparing and accurately displaying the growth percentage and body mass index of the child from time to time.
- Maintain drug dosages based on the patient’s data, providing the most accurate, up-to-date and complete information, thereby reducing chances of misdiagnosis or prescribing wrong medication.
- Incorporate documentation templates that physicians can access whenever required. Lab results can be included in the patient’s records, which eliminates the risks of wrong treatment due to challenges like illegible handwriting or misplaced records.
- Record and display immunization data, allowing pediatricians to provide information about completed immunizations, configure to the practice’s vaccine schedule, and get reminders to prevent missed immunizations.
However, the AAP identifies several issues that pediatricians continue to face when it comes to electronic health records such as interoperability, patient safety and information security. The 21st Century Cures Act addresses the problem of interoperability by calling for:
- The development of a framework to facilitate information exchange between EHRs
- Instituting penalties for information blocking
- Encouraging two-way communication between EHR systems and registries.
The law also supports certification and development of patient-centered EHRs to improve patient access to secure and up-to-date health information.
Proper record-keeping is also crucial to avoid allegations of pediatric malpractice. The Public Health Law Map report notes that many of the cases in which pediatricians are charged with failure to diagnose a condition are actually due to a systems failure in the physician’s office routine rather than an error in medical judgment. Pediatricians need to pay special attention to documenting all findings about the patient’s condition, the treatment plan and any unusual events. Failure to maintain clear and concise records can mask the presence and absence of diagnostic signs that indicate a serious illness in children and adolescents.
A study by the AAP covering the period from July to December 2012 showed that the number of office-based pediatricians who are using an EHR rose steadily from 2009 to almost 80%. EHR cost and reduction in productivity remain serious concerns. Even with the widespread implementation of EHRs by pediatricians, only some use a basic or fully functional EHR, and even fewer have added pediatric functionality. In this context, the EHR certification process visualized by the 21st Century Cures Act has a key role in improving the functionalities used by pediatricians and increasing efficiency, data exchange capability, and general EHR functionality.
Pediatric medical transcription services provide the solution to many of these challenges. Outsourcing clinical documentation tasks to an experienced medical transcription company can minimize EHR data entry errors, ensure comprehensive record-keeping, expedite patient care, streamline workflow within the practice, free up time for physicians and also reduce workplace chaos. Further, as medical transcription services for practices are based on volume of work done, physicians can avoid the expenses associated with maintaining an in-house team to handle transcription tasks.