Streamline or Slipup?
May 28, 2014 08:49PM
By MED Magazine
By Shelly M. Davis, BSN, JD
Despite the many advantages of the electronic health record (EHR) for both patients and health care facilities, concerns linger regarding the implementation of these systems. For example, while EHR has improved documentation for health care providers in many aspects, it has also introduced new and complex problems found only in an electronic environment.
Here are a few ways to think about EHR best practices — and help you think before you click.
Templates can be a good thing
Well‑designed EHR templates offer obvious advantages. However, if used inappropriately, templates can cause as many problems as they solve. For example, many health care providers simply “carry forward” pre‑existing information from one template to the next. While much of a patient’s demographic information may remain consistent over time, it is highly unlikely that incident‑specific information will, or should, remain the same.
The point here is simple: Templates should not be automatically pre‑populated with data. If this is part of your EHR work flow, ensure that any pre‑populated data is accurate and try to limit pre‑populated fields to demographic information. If it is not, then it is your responsibility to correct the information before signing off on the documentation generated by that template work flow. One mistake in a single template field can lead to patient injury, and to potential malpractice claims. While it might sound time‑consuming, this task will take much less time than being involved in a lawsuit. Imagine showing a jury six days of Progress Notes that are identical. This happens, and should not.
Cut‑and‑paste with care
The cut‑and‑paste feature in the EHR can be a great timesaver, but like templates, cut‑and‑paste is often used inappropriately. Don’t cut‑and‑paste information that has not been independently obtained or verified. We know patients’ histories and recollections can change depending on many factors, such as who is asking the questions, how questions are asked, a patient’s anxiety or pain level, current medications, and the presence of family members at the time of questioning.
Obtaining complete and accurate patient history is essential. If you simply rely on another provider’s data, there is a risk of over‑testing because you have under‑listened. Why? Because unfortunately, many physicians perceive it to be simpler and quicker to order tests than to listen and think about the big picture.
There have been many documented cases where health information was pasted into an improper location of a patient’s chart, where copied data contradicted the template‑generated content, or was lost altogether because it was pasted into the wrong patient’s EHR. So use cut‑and‑paste with care. Your patient’s safety is more important than the few minutes this feature can save you.
Alert and alarm fatigue
For many, alert fatigue has become an EHR nightmare. While these warnings are ostensibly beneficial — by reminding providers of important information — alerts can be so frequent that providers become desensitized to them, and hence shut them off with indifference.
But alert fatigue was a concern for years before the advent of the EHR. For example, there have been many cases of monitor and pain pump alarms being shut off without heed, resulting in severe injury for the patient, and sometimes death.
The phenomenon of alarm and alert fatigue needs immediate attention within the health care industry. Getting providers to acknowledge the importance of alarm and alert fatigue, and implementing regular reminders about their importance, is only one step toward avoiding adverse outcomes. Another more powerful step is to involve providers in defining the appropriate thresholds that trigger the alerts and alarms.
Keep in mind that the patient record, no matter the format, is the prime communication tool used to facilitate reasonable care and treatment. Documentation in the EHR needs to be meaningful, objective and based upon patient presentation. Thus, documentation needs the utmost attention. With appropriate use of templates, cutting and pasting, and alerts, the EHR will achieve its original and ultimate goal: improving patient safety.
This article was submitted by Shelly M. Davis, BSN, JD, a Senior Claim Consultant at MMIC. This article originally appeared in the Summer 2013 issue of Brink, a quarterly risk solutions magazine published by MMIC. For more information, visit MMICgroup.com.