Would use of technology lead to more medical record errors

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Would Use Of Technology Lead to More Medical Record Errors?

EHRs are creating many unpredictable errors that may prove costly in the long run. This may affect the quality of patient care, patient safety and even medical record review for litigation.

Any kind of transition is fraught with challenges in one form or other. So why should EMR transition be any different? The EMR transition has been made mandatory with the best interests of patients, physicians and payers in mind but needless to say, this passage is not at all smooth. The new digital technology is bound to bring in more medical record errors or varying types of medical record errors.

Doorways for Medical Record Errors • Comprehensiveness of medical data transfer from paper to electronic format: This is one area where errors or shortcomings are likely to occur. Physicians and facilities have voluminous patient data on paper and the question is how much of the information to transfer. Healthcare providers may use their own discretion to determine the amount of data to be transferred and this may have a negative impact in the long run.

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• Clarity of document scans: Medical document scanning is the practical and easy way of digitizing paper records. The clarity of the scans has an important role to play in ensuring the accuracy of documentation. Moreover, errors already present in the paper medical records may migrate to the digital records and lead to further errors and ambiguity.

• The risk inherent in sharing medical records: The new medical record system is being implemented with a view to facilitate sharing of patient records and ensure coordinated care. However, loopholes for serious errors exist. For instance, if a mistake is made and goes unidentified, it will create a wave effect and ultimately lead to very grave issues. This is applicable for erratic entries for test results and personal health details.

• Existence of duplicate records: The same patient may be treated under different names by different providers. This can be the case with a patient who is identified by her maiden name with one provider and married name with another provider.

• Errors caused by speech recognition software: Speech recognition software is still developing and is prone to errors. Mistakes are seen to occur in recognizing the patient’s name, drugs, diagnoses and treatments provided.

An Example in Hand – Faulty EHR Systems in Emergency Departments ModernHealthcare.com highlights a report that refers to the serious concerns posed by electronic health record systems. The report is by two emergency physicians’ study groups that found that EHR systems used in EDs are so weighed down by poor http://www.mosmedicalrecordreview.com/

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data displays, and plagued by numerous alerts warning of potential patient safety issues that they can ultimately lead to user alert fatigue and may even generate wrong physician orders. Healthcare providers on their part are mostly confused with no required information that could help fix the issues. Quite alarmingly enough, a number of clinical practitioners are reporting a considerable increase in the number of wrong patient/wrong order errors when using the computerized physician order entry component of these systems. This speaks volumes of the need to expedite EHR monitoring in emergency departments to ensure that patient safety and care are not compromised. In fact, many scholarly journals including the New England Journal of Medicine have already published articles emphasizing the presence of actual risks when using electronic health records and other forms of health information technology.

The gravity of the problem lies in the fact that system functionality varies a great deal for the EHRs used in emergency departments, whether these are designed in-house, commercial systems made specifically for EDs or are part of multidepartment, multifunctional, commercial “enterprise�

EHRs. The inconsistency has a negative impact on physician workflow, communication, decision making and thereby affects patient safety and the quality of care provided. Experts point out the need for EHR vendors to consider the seriousness of the situation and develop foolproof products instead of having clinicians tussle with complex electronic systems.

Medical Record Review amidst This Uncertainty So how does medical record review for legal and medical purposes fare amidst all this confusion? Undoubtedly, medical http://www.mosmedicalrecordreview.com/

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http://www.mosmedicalrecordreview.com/

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litigators will have a tough time reviewing the medical documentation especially if there are intentional or inadvertent errors carried from one system to another. You can’t rule out the fact that use of technology, especially technology that is not perfected yet, may hinder smooth medical record review for litigation purposes. Any erroneous documentation can lead to a wrong view of the case and consequent wrong decision making.

Now it has become more important for lawyers to rely on professional medical review services to ensure more accurate medical reviews and clear understanding of a case. Though it may not solve the problems in their entirety, experienced reviewers will be able to identify possible errors and discrepancies in the medical reports. Being trained in medical terminology and with a good awareness of medical procedures and treatments, they will more easily spot out issues including wrong drug names, possibilities of wrong/missed diagnoses and other such issues.

The possibility of technology leading to more medical errors is a frightening prospect indeed. However, EMR transition is necessary and it is the onus of electronic health record developers to devise systems that will improve clinician and facility efficiency and help meet the healthcare goals set by the federal government.

Posted by MOS Medical Record Review Company http://www.mosmedicalrecordreview.com/

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