EMR Implementation and Protecting Patients

EMR implementation is happening everywhere we turn. This is a definite step in the right direction but there are problems with this (this is not a productivity post).  Next up is voice recognition, speech understanding technology, SR, VR, whatever you're calling it. Hospitals, clinics, physicians are saving big money (are they?) by the changes happening, but who is thinking about the quality of the patient record in all of this?

This is my business....Transcribing patient reports and being a patient myself, this is hot topic. All the pointing and clicking leaves little to not only the patient's narrative but also the doctor's voice. Then, there are the doctors' speech who could never, in their lifetime, be recognized and plopped into a patient's record without editing of some sort (or a complete re-type).  

One lesson that has stuck with me from a mentor of mine is when transcribing, we should not be messing with the doctor's voice.  Yes, we edit (according to client preference of course) and fix glaring grammatical errors, but a good transcriptionist will NOT mess with the doctor's voice. He speaks how he speaks, and we need to respect that.

To answer my earlier question -- there are some driving forces in our business who are interested in fighting for clinical documentation quality assurance. Kathy Nicholls put together a study that is so incredibly interesting I wish more folks would take notice.  See her blog post about it at Identifying Errors, Protecting Patients Report.  There are the all-to-common R/L discrepancies, medication dosage errors (mostly on account of SRT), lab values, etc., but check out these numbers:

In looking at the types of errors, here’s what we see:

• Dictated left/right inconsistencies: 1.92% of total
• Discrepancies/inconsistencies: 7.93% of total
• Lab value errors: 2.64% of total
• Medication Error in dosage: 2.88% of total
• Medication Error in name of drug: 3.13% of total
• Patient Demographics/
• Incorrect Information: 11.78% of total
• SRT Errors 69.71% of total

Now, with these percentages one must look at the larger scale of this, and Kathy said it best in her comment on the blog:

.....those percentages seem small, until you extrapolate it to the bigger picture. The reports from the CDC show a total of 34.4 million inpatient admissions per year, 109.9 million outpatient visits per year, and 123.8 million ER visits per year. If you assume (loosely) that each inpatient visit generates 3 reports of some kind (I’m thinking history and physical, procedure note of some kind, and a discharge summary) and each of the other types each has one report, that equals 336.9 million reports per year. Now that 1% becomes 3.37 million with errors, 2% 6.74 million, and 3% 10.1 million. It puts a new light on that for sure. And you’re also right, no one wants that 1% to be their family member or their personal record.

I think the point is that we have to find ways to share this information with the RIGHT people. It’s not about saying we don’t want the technology as it does bring some good things. It IS about calling for initiatives that put a quality check in place for information that goes into the EHR before it harms a patient.

Here's a sampling of the errors found:

• Penicillin listed as an allergy and then prescribed as a discharge medication.
• Metoprolol 500 mg
• “SPECT myocardial infarction” instead of “SPECT myocardial perfusion.”

Errors from SRT

• “Informed consent was obtained” became “informed consent for suicide was obtained.”
• Glyburide became Namenda. These two aren’t even close in sound, and so the patient with diabetes ends up getting treatment for Alzheimer’s.
• Tramadol became Trileptal. Clearly a medication for epilepsy isn’t going to help this patient’s rheumatoid arthritis very much.

This is very troubling and I hope those in the clinical documentation field (including EMR vendors) will not take this lightly. Do we risk harming patients just to save facilities money?  And, to that end, how much are they truly saving when you add in malpractice, EMR implementation productivity loss, and all the other "consequences" that come along with it?  

There are transcription companies (us, for one) who offer an alternative which is a perfect solution in my opinion. If the EMR allows structured data, a doctor can dictate the visit, which we all know is the quickest way to document the encounter, and our software plugs the dictation into the appropriate areas of the EMR. We  are checking and double checking patient record QUALITY!  Without quality checks (by folks who actually know what to look for) of some sort the facilities, offices, clinics WILL lose patients one way or the other.

If you're a patient, REQUEST your record, find out about WHAT QUALITY CHECKS are in place in handling YOUR record -- it's YOUR right.

Have you or a loved one had an issue with your medical record AND how it was handled?  I would love to hear from you!   

If you're interested in our services, please contact us through our website Just My Type Transcription or at info (at) justmytypetranscription(dot) com.