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Lucia DiVenere, MA (October 2011)
The medical record has evolved considerably since it originated in ancient Greece as a narrative of cure.1 For one thing, it’s now electronic. For another, it’s no longer a medical record but a health record. According to the US Department of Health and Human Services, the distinction is not a trivial one. A medical record is used by clinicians mostly for diagnosis and treatment, whereas the health record focuses on the total wellbeing of the patient.2 The medical record is used primarily within a practice. The electronic health record (EHR) reaches across borders to other offices, institutions, and clinicians.
Use of the EHR has been stimulated by the Health Information Technology for Economic and Clinical Health Act,3 which offers grants and incentives for “meaningful use” of electronic records.4 After 2014, medical practices that do not use EHRs will face a financial penalty that amounts to 2% of 2013 clinical revenue.
EHRs have been hailed as a panacea and derided as anathema. Whatever your perspective, there is no denying that they dramatically increase the immediate and easy availability of information and, therefore, influence decision-making in regard to medical care, cost-effectiveness, and patient safety. EHRs have the potential to improve communication, broaden access to information, and help guide clinical decision-making through the use of best-practice algorithms. When used properly—which means taking advantage of the EHR’s full potential and adapting to the way information is organized and analyzed—the EHR can reduce adverse events and help defend the appropriateness of the care provided. This lowers your medicolegal risk. When used improperly or haphazardly, they may increase that risk. In this article, we elaborate on both.
EHRs have many benefits
Improved communication. EHRs facilitate communication between healthcare providers. A primary care physician can access a consultant’s report practically as it is written. Providers also can carry on a dialogue electronically, planning together for care that will best serve the patient, with less redundancy and time.
The EHR also facilitates communication between physician and patient, allowing the physician to see the patient’s recent history and plan her management while speaking to her on the phone. Issues can be addressed with greater accuracy and expediency, leading to reduced anxiety for the patient and increased compliance.
Seamless integration. Information can be entered into the EHR and integrated into the full record more seamlessly than it is with written records. And data can be entered once and used many times.
Enhanced decision-making. Decision-making depends on careful analysis of a clinical scenario. Protocols, templates, and order sets embedded in the EHR can reduce medical errors by identifying scenarios for the physician to review.5,6
The EHR can also highlight adverse drug-drug interactions and help avoid potential allergic reactions. Murphy and colleagues reported a reduction of medical errors by utilizing a pharmacy-driven EHR component—a reduction from 90% to 47% on the surgical unit and from 57% to 33% on the medicine unit.7
Improved documentation. The EHR can enhance documentation by offering specific and detailed templates for informed consent, making it more comprehensive than a handwritten notation of the risks and benefits.
Decipherability is another strength of the EHR. Because physicians are notorious for poor handwriting skills, some hospitals now require a writing sample as part of their privileging process. The EHR avoids this issue entirely.8 Typos and grammatical errors are minimized by spellchecking and grammar-correcting programs written into the EHR.
Quality assurance. Timely evaluation of approaches to clinical care is available to physicians as well as hospitals that use EHRs.9 An individual physician can perform personal quality-assurance audits. And hospital management can gather cumulative statistics more quickly and easily.5,6,10,11
Patient data can be accessed independent of medical department, with lab tests, imaging studies, and pathology reports readily available for review. And accessibility is available regardless of geographic location.
EHRs are not perfect, and neither are their users. EHRs present the potential for problems related to absent or erroneous data entry, patient privacy issues, misunderstanding and misuse of software, and development of metadata.
With initial use, EHRs can create documentation gaps with the transition from paper to electronic records. In addition, inadequate provider training can create new error pathways, and a failure to use EHRs consistently can lead to loss of data and communication errors. These gaps and errors can increase medicolegal risk, as can the more extensive documentation often seen with early use, which creates more discoverable data. The temptation to cut and paste risks repeating earlier errors and omitting new information.