Documenting In The Age of EMR SPAP 2019
EMR/EHR Beginnings • Mid 1960’sClinical Information Systems • Lockheed -> Tenhnicon -> TDS Healthcare -> Eclipsys -> Allscripts • University of Utah with 3M developed Health Evaluation through Local Processing (HELP) • Mass General with Harvard made Computer Stored Ambulatory Record (COSTAR) in 1968 • 1970’s Department of Veteran Affairs made VistA • 1980-90’s Institute of Medicine published a study to argue the case for using EHR
Recent Developments • President Bush mentioned in 2004 State of the Union • President Obama incorporated EHR into the American Recovery and Reinvestment Act of 2009 as part of the Health Information Technology for Economic and Clinical Health Act (HITECH) • Where “Meaningful Use” started which mandates transition to HER treating patients covered by government programs
Most Common EMRs
Pediatric patient safety event report data from inpatient and outpatient settings that were entered in the period 2012–17 were retrieved from three large academic health care institutions (two stand-alone pediatric institutions and one adult and pediatric institution) that used Epic and Cerner EHRs (two institutions used Epic, and one used Cerner).
More than 3,000 medical errors at pediatric hospitals from 2012 to 2017 were due in part to EMR/EHR problems, a study in Health Affairs found. About 1 in 5 of these could have caused patient harm.
In the first evaluation of its kind, we found that nearly two-thirds of safety reports related to the EHR and medication at three pediatric hospitals were associated with usability issues.
Where We Make Mistakes • Demographics • Templates • Importing (copy and paste) • Actual/factual documentation • Privacy
Demographics • Name issues • Gender issues • Wrong chart
Name Issues • Sound alike names • Spacing or punctation • Computer problems
Gender Issues • EMR limitations • Insurance companies • Need factual information
Wrong Patient • Same issues from paper charts, but can be easier to miss • More mistakes in a busier practice • Name issues (demographics)
Templates • Insurance companies • Personalization • Right template • Time saver?
Insurance Companies • MagMutual one of the first to oppose templates • Templates the most common place for errors to happen • Improved over time
Personalization • Make it your own • Metadata mark
Make It Your Own • Design your own templates with your wording • Document or change something
Metadata
Importing • Cloning • Every chart looks the same
Cloning
Documenting • Did you actually do it? • Did you do it and not document? • Personalization
In the past: You did not do it if you did not document it!
Did you do it? • If exam and other elements are left unaltered its harder to prove they were done • Finished note looks incomplete at times
Privacy • Portals • Printed notes • Insurance EOB • Can lead to missed information
Restrictions not always good
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