The use of electronic health records (EHRs) has increased rapidly in recent times. According to the Office of the National Coordination for Health Information Technology, the adoption of EHR systems in the U.S. rose more than five times in non-federal acute care hospitals during 2008-2013. Up to 93 percent of hospitals had EHR systems by 2013. However, recent surveys indicate that EHRs are error-prone, affect the integrity of patient information, and increase the risks of medical malpractice.
EHR Data Entry Errors – A Major Problem
According to a North Bay Business Journal report, the errors identified in recent study by The Doctors Company, a Napa-based medical malpractice insurance company include:
- data entry errors
- health records in multiple formats and stored in several locations
- conversion from paper to digital files
- use of copy-paste function to enter data without modification
- lack of EHR training and education
The company stated that it found that as the use of EHRs became widespread, errors and malpractice liability also increased. Up to 43 percent of EHR claim events were reported from a hospital clinic or doctor’s office, followed by ambulatory or day surgery center, a patient’s room, the operating room, emergency room, labor and delivery, radiology and imaging, and dentistry and oral surgery.
An earlier study of EHR records in the Veterans Health Administration’s reported that 84 percent of progress notes had at least one documentation error. These included:copied text, incomplete or inaccurate templates, documentation entered in the wrong patient’s medical record, inconsistent text, and outdated embedded objects.
Role of Medical Transcription Services
Partnering with a professional medical transcription service company can help health care providers circumvent EHR data entry errors. In fact, there are many physician groups and hospitals that now resort to outsourcing medical transcription to get patient encounters edited and transcribed so that they can be uploaded to their EHRs.
According to a recent article in Medical Economics, the critical role of medical transcription companies in ensuring EHR integrityis recognized by the Association for Healthcare Documentation Integrity (AHDI). The team of certified medical transcriptionists and documentation specialists in a reliable company are well aware about the importance of clinical clarity and can provide neat, clean andaccurate, high-integrity documentation by collaborating closely with physicians. The author notes that these highly skilled specialists can ensure accuracy, identify gaps, errors, and inconsistencies that may compromise patient health and compliance goals. Accordingly, AHDI recommends including wording that expands the definition of “non-physician members of the care team” to contain certified healthcare documentation specialists and certified medical transcriptionists.