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.
· 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:
· 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 patients.