Healthcare News & Insights

Are EHR shortcuts causing as many problems as they solve?

Using electronic health records can make visits more efficient  for both patients and health care providers. But overuse of certain kinds of shortcuts turns that benefit into a potential problem.

A recent audit of EHRs by researchers from the University of Washington Medical School in Seattle turned up several disturbing findings.

Overuse of three common shortcuts was creating incorrect or misleading patient records and putting patients at risk for improper care. The shortcuts were:

  1. Cloning — Physicians can copy/paste information such as prior medical history, demographic info, etc., from previous visits (or even other patients’ records) and paste it into the current record to save time.
  2. Templates — Templates are designed to prompt documentation, but some practices have theirs set up to essentially pre-fill information, which the physician updates as necessary. (Example: Organ system reviews are automatically filled in as “negative,” and the physician is expected to check a box to switch the answer to “positive” based on patient answers.)
  3. Macros — Used by teaching physicians, macros let users customize a large amount of data quickly. For example, typing “.liv” to indicate a liver exam would then bring up a drop-down menu of other relevant information the physician can choose to create a more detailed record.

It’s easy to see how these elements save time and help physicians create uniform patient records. But they can lead to problems when doctors become too reliant on the short-cuts, or miss data that needs to be updated.

In the audit, researchers found some glaring errors that were attributable to short-cuts. For example: One record dated April 25, said a patient would be given a holter heart monitor evaluation until May 12. A record for the same patient in September contained the same note — without any update as to the status of the evaluation or what the results were of the presumably completed test.

In another case, a patient record template indicated abdominal pain of an 8 on a 1-10 scale. The physician notes for the same visit indicate no pain and an benign exam. Most likely, the doctor failed to update the template from a prior visit.

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