Documenting In The Age of EMRSPAP 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