Accuracy of Electronic Health Records
Electronic Health Records (EHRs) are digital patient health records, which are meant to be easily accessed and shared with authorized healthcare providers. In an ideal world, this would allow for well-informed and holistic care coordinated between multiple providers over a patient’s lifetime. Several government incentives have been created in the last twenty years in an effort to urge the adoption and use of electronic medical records, including the Recovery Act/ HITECH Act under the Obama administration. Additionally, as early as 1995, the Center for Medicare and Medicaid Services (CMS) has shaped the content of physician documentation by setting guidelines that tie reimbursement to documentation [1]. While adoption of EHRs has become more widespread [2], the accuracy and quality of physician documentation using EHRs compared to paper records is still unclear.
A 2019 study of nine emergency medicine residents discovered inconsistencies in review of systems (ROS) and physical examination (PE) findings between electronic physician documentation and observed behaviors [3]. A retrospective study of 500 medical charts found that inaccurate PE documentation was significantly more likely in EHRs compared to paper documentation. However, expected PE findings were more likely to be omitted in paper charts than in EHRs. The study also found that level of training influenced accuracy. When compared to attending physicians, residents had fewer inaccuracies (5.3% vs 17.3%) and fewer omissions (16.8% vs 33.9%) in both paper charts and EHRs. Despite these discrepancies, it is worth noting that overall accuracy was poor for both methods with only 54.4% and 58.4% accurately documenting PE findings in paper and electronic systems, respectively [4].
There are many factors that might influence the inaccuracy of documentation. These may include the language of encounter, use of scribes, time between encounter and completion of note, and auto-populated text in the form of templates, drop-down menus, check boxes, and copy and paste [3, 4]. Site-specific factors such as severity and number of patients seen per hour, patient severity, and co-working conditions may also influence documentation inaccuracy [3]. Differences in accuracy between residents and attending physicians may be influenced by the amount of oversight as well as comfort multitasking and familiarity with electronic systems [4].
As EHRs become more widely integrated into medical systems, addressing inaccurate documentation has become increasingly urgent. Some call for the removal of documentation incentives that call for lengthy ROS and PE [5], which may overburden physicians and lead to poor practices such reliance on auto-fill and copy-paste methods. Other avenues worth investigating that are not covered by either study cited above, are patient outcomes and the undesired or adverse effects on patient care as a result of inaccurate documentation. Looking forward, it has been suggested that researchers and policy-makers should invest in incentives that encourage accurate documentation. These include training programs[4] and revised documentation requirements[3] that lessen unnecessary burdens and workflow disruptions on physicians.
References
1. Centers for Medicare & Medicaid Services, 1995 Documentation Guidelines for Evaluation and Management
Services. 1995.
2. The Office of the National Coordinator for Health Information Technology, 2018 Report to Congress: Annual Update on the Adoption of a Nationwide System for the Electronic Use and Exchange of Health Information. 2018.
3. Berdahl, C.T., et al., Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior. JAMA Netw Open, 2019. 2(9): p. e1911390.
4. Yadav, S., et al., Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record. J Am Med Inform Assoc, 2017. 24(1): p. 140-144.
5. Yackel, T.K.P.B.M.B.T., Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians Annals of Internal Medicine, 2015. 162(4): p. 301-303.