Why your EHR note may not be accurate

With paper exam notes, the doctor and staff record information and the note reflects what they recorded.  Unfortunately, EHR based notes may not be as direct.

Many EHR systems store the information that you enter in one way, and offer a variety of presentation and reporting options.  The ability of the EHR to offer multiple presentation options is a powerful tool.  For example,

You may generate an exam note, referral form, and a disability notice from a single set of exam information, or you may view the patient information on a formatted screen, in note form, and even in a longitudinal format depending on the EHR.

However, EHR features are frequently based on programmable interpretations, translations, summarizations, and even derivations by the scripts that create the desired view.  For example,

  • The script may display a message that is not in the exam note but derived from the note.  For example, a health maintenance warning for mammograms may be based on the date of the patient’s last mammogram.  Similarly, a message to come in for a periodic visit may be presented based on previous services or problems.  If the underlying EHR information is not properly recorded, inappropriate notes may be added, and/or critical notes not included.
  • A patient problem may be presented in text form without the ICD9 or even using another text description.  For example, one system used a general migraine code (346.80) under a problem list labeled migraine, when in fact the one of the 14 more specific migraine codes was more appropriate for billing and problem definition purposes.  In another instance, the labeled text item was connected to a more specific ICD9 code than indicated in the description.  The lack of precision in the underlying codes could lead to a wide range of patient service issues.
  • Some EHRs link partial medication information in the exam note to very specific prescription information that may lead to a distortion in the exam information.  For example, several EHRs use a listing of the drug name in the exam note and generate a prescription for a specific strength and form. When this prescription is processed in the prescription module, the doctor can change the prescription, but the exam note is not updated.
  • Some EHR systems allow the user to change the note, while the connected information stays the same.  For example, you may change the diagnostic order on the note, but the selected items associated with the original order remains.  Other EHRs require recording the order in several places, which could be separately modified due to a clinical or patient service issue.
  • A script may add text to the document that was not contained in the medical record.  For example, some EHRs include information in the letter template that is not reflected in the patient’s medical record.

These problems must be addressed by insuring that you adequately understand the operation of your EHR as well as the clinical content used to document patient services.  Such a process requires vetting the clinical content as well as the documents and information that can be printed from your patient record.  Otherwise, you may have records that do not accurately present the care and due diligence provided to your patient.

Ron Sterling is founder of Sterling Solutions, which guides medical practices in the use of technology to improve patient services and practice operations.

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  • Anonymous

    This was a great article highlighting the human factors involved with data entry for EHRs. It is a strong reason why patients should be allowed to view their EHR for accuracy.  There are a couple of other instances where accuracy can be compromised.  When ordering lab tests or procedures, a diagnosis must be entered.  It might be that the diagnosis was not established but is one that is suspected.  The entered diagnosis then finds its way to the patients diagnosis list. It is not deleted in the diagnosis list by the provider, making it a definite diagnosis to the observer. Sometimes a new drug will not make it to the EHR medication list and must be entered in a different manner, and providers in haste might do this wrong or substitute a known drug that is close to it by mistake (ex. a combination drug might have its components entered with the wrong doses when done separately). If an ordered test or procedure is cancelled by the patient or another provider, it might not be noted and the ordered test is still in the system. The automatic E&M billing by EHR providers should not be blindly followed, because it will lead to significant mistakes. There are many other examples, all of which illustrate the human factor and liabilities involved in EHRs.  They are tools to be used correctly and should not be relied upon to be totally automated. 

  • civis isus

    why not simply state that recording observations in any format is fraught with challenges, and let it go at that?

    one could as easily gin up a laundry list of the shortcomings of pen & ink notes stuffed, isolated and unsummarizable across a practice population, in manila folders

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    All these systems are not designed to be physician or patient friendly. They are designed by IT personnel with coding personnel for the acquiring and transmission of data that the large insurers and federal government wish to track. Most of the notes I receive from colleagues about my patients are worthless and hopefully in the assessment section there are a few dictated or typed words truly indicating the consultants thoughts.
    If the government truly was interested in meaningful use it would be paying the vendors directly instead of the physicians when the software is fully functional the physician office or clinic or hospital is meeting meaningful use guidelines accurately. The vendors would then be designing software and training their staff educators in a manner that quickly and easily allowed physician offices to comply. The current manner of offering a repayment over five years after the physician has fronted tens of thousands of dollars for these poorly thought out and functioning systems provides little incentive for the manufacturers or local vendors to get it right the first time

    • http://twitter.com/DrBonesMD Stephen Rockower

      Steve, You are spot on.  All of these systems are not designed for doctors.  They are designed for executives and bean counters who want data data data, so they can see where we are doing it wrong.  “You cannot improve what you don’t measure.  What gets measured gets done.  So, be careful what you measure.”  There are precious few docs in the software design business.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    My medical school days, I had a demonstration of computer software to help teach medical students. The virtual patient.

    Ninguem: “Good morning Mr. Smith” [meaning, the character created by the computer].

    Mr. Smith: “I’m feeling terrible Dr. Ninguem. My stomach hurts.”

    Ninguem: “Where does it hurt?”

    Mr. Smith: Well, it started near my bellybutton, but now it’s moved to the lower right side of my abdomen”

    Long story short, you ask various questions, you get the clinical
    findings of anorexia, fever, go to physical findings of rebound
    tenderness, labs with elevated white count, etc……..

    I failed the simulation. It ended like this.

    “What’s your diagnosis, Dr. Ninguem?”


    “Wrong Dr. Ninguem. The patient had ACUTE APPENDICITIS”

    I didn’t enter the word “acute”, just “appendicitis”. So I failed. Hey, I
    still graduated. Hopefully, they improved the software since my med
    school days.

    Like it or not, and I mean to the technical people in medical
    informantics, the EHR is supposed to adapt to the DOCTOR, not the other
    way around. People seem to forget that the purpose of a EHR is to make
    it easier for the doctor to care for the patient. Gathering statistics,
    administration, billing, medicolegal, are all secondary. That it seems
    the other way around to many people is sad, but not surprising.

    • civis isus

      Ninguem, NO ONE, except your mother, and maybe other immediate family members, cares about you. That’s not to slight you, or make you “sad”. It’s just the way it is. You should try starting with that non-judgmental fact.

      People seeking help with ailments want the ailment to be gone. THEY DO NOT CARE WHAT MIGHT BE GOOD FOR YOU. YOU are “secondary”. You might even only be tertiary. You are an inconvenience. If god, or magic, or something else easier than spending even one second with you would make people feel better, they would choose it.

      Your insistence, in post after post here at KevinMD, on making yourself central to anyone’s health other than your own, is, truly, sad.

      • http://twitter.com/DrBonesMD Stephen Rockower

        civis.  Be civil.

    • Anonymous

      By and large it is an accurate statement that
      EMR/EHR are not made for or by doctors. However it is primarily created to keep
      history of what care givers are doing or have done. It is definitely not
      designed to add or improve medical skills or knowledge because then it will be
      tool for education of caregivers. Just like surgical tools are created by non-surgeons
      but it will be added value if a surgeon designs them; EMR/EHR do not need
      doctors’ participation in designing or creation of software but they must be
      included in the Beta Stage where actual usage is tested. No two caregivers I
      know record information in any one format or style and that issue is more poignant
      with the senior physicians than those who are entering the profession or have
      recently entered. These are management tools and are linked to managements’
      goals and objectives and you guessed it, “healthy bottom-line” for the

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    All the shortcomings described here can be classified as software defects, and as such they ought to be fixed by the vendor. There should be no mysterious scripts running somewhere and altering the medical record, changing SIGs and diagnoses, or whatever else mentioned in the article and subsequent comments. This is not a usability issue or even a utility issue – it’s a bunch of bugs.

    As to the length and vapid content of notes, one needs to understand that this is created by doctors who choose to click on buttons that add this irrelevant content to the note. Yes, this is billing driven, but it is not inserted there by the software, unless somebody decides to insert it, usually to satisfy the payers. So if there is an issue here, it should be directed to those who make the rules, because EHR vendors do not. They just provide the tools to satisfy said rules. It is ultimately your choice.

    I would also disagree with Dr. Reznick’s opinion that EHRs are designed by IT folks and billers. There are plenty of physicians and nurses involved with design and the biller thing is pure mythology. The problem is that for large systems, the customer (who writes the check) is not the doctor, and that customer has different goals in mind other than “just” patient care.

    I also don’t know that the government needs to pay anybody anything in excess of what the product is really worth. In absence of incentives (bribery), EHR vendors, just like all other sellers, would be forced to create products that somebody wants to pay for, and if they can’t, they would go out of business, so why not define interoperability standards and leave it at that? Let the market do its thing…..

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      There is little incentive for the vendor to fix anything. They have a trapped market who knows that if they do not use EHRs by 2015 they start getting penalized financially against their Medicare reimbursements.
      It is possible to customize your EHR notes by typing or dictating. The problem is that typing doesnt trigger the software that you have met the ” meaningful use” criteria and qualify for the ARRA 2008 incentive reimbursement. The fact is that computer entry takes time and slows down healthcare providers. In my smaller practice with more time per patient I have the luxury of working through the software bugs in systems like the All Scripts My Way software. Colleagues seeing patients in 10-15 minute slots and seeing 40 patients a day do not have that luxury of time. When their system doesnt work they do not have the time to call their vendors help center in Peshwar or hold on while the tech in Mumbai reads from a script all the steps you have already taken before calling them.
      The trend to put in computerized order entry and electronic health records is driven by one thing, the desire to receive the $44K incentive over five years if you are a provider or the $11 million if you are a hospital.   While I accept Margarit’s opinion that physicians played a role in the development of this software I would suspect these were not physicians who actually see and treat patients .

  • Anonymous

    Ron Sterling has effectively identified the
    shortcomings of HER software; however it appears to be a scenario of a
    particular HER software. Most of the issues are related to poor designing of
    the software itself and also the dictionary program not loaded with accurate
    and mandatory descriptions. The post encounter changes made in any previously
    recorded information has to go through the editing interface and that ought to automatically
    over write the prior entries at best or at least set off a flag to do so
    manually by returning to the original document. Especially for Rx changes it is
    of paramount importance that all documents has same source information or
    alternatively recorded changes have audit trail to the original one. If the
    billing software gets the data from the encounter documentation and changes are
    made later there will be serious billing errors leading to investigations from
    the Third Party Payers.  The coding
    discrepancies occurring mentioned in the article also are indicative of poor
    logical interfacing of the software and all of which can be detected during the
    evaluation phase prior to purchasing the HER software. Most sophisticated EMR/HER/Practice
    Mana. A transaction based testing will bring out the defects identified in this
    article. It will serve as a guide for any practices if they are contemplating
    or in process of purchasing a new EMR/HER system.

  • Anonymous

    Some folks will stop at nothing to obstruct progress. Must be a “Repeal” Republican. 

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