Electronic health records have had a major impact on the workflow and productivity of health care organizations since they became one of the most popular health IT devices available. They have been shown to enhance several aspects of patient care and communication. They also alleviate many of the cumbersome documentation and note-taking processes, reducing errors along the way.
One of the most beneficial aspects of EHR systems is that they significantly improve the quality of notes and documents handled by physicians. Before the adoption of EHRs, many practices reported several errors in documents, such as prescription notes. EHRs provide alerts that are meant to catch these mistakes and even reduce the time it takes to create the forms required in appointments, opening up more time to spend with the patient.
According to the American Chiropractic Association, an efficient EHR system has the potential to drastically improve the accuracy and quality of documentation. Its success is a result of its ability to prompt physicians to include the appropriate information to fully complete a patient record in a timely manner. Before the implementation of the EHR system, doctors would have a choice – they could spend more time with patients, rushing the documentation process and risking input errors, or they could spend the appropriate amount of time creating notes and documents, missing important face time.
EHR systems are equipped with useful templates that enable physicians to create notes at twice the speed as it took to create written notes. Specialty EHRs enhance the process even further by providing forms and templates catering specifically to the unique needs of the practice. Once a specialty practice becomes familiar with the EHR system, daily workflow is much more efficient.
"Much of what we do in chiropractic is the same between each visit; the findings are similar. Once you build a note for a patient, you can modify the note for the next visit," said Richard Cole, a member of the ACA's EHR Task Force, as quoted by the ACA.
In addition to making documentation easier, EHRs are equipped with prompts that have the potential to increase patient safety. For example, there are many patients who take a number of different medications and do not even know the details of each medication or what they are used for. A lot of times they cannot remember their proper names, either. This lack of understanding largely affects how patients end up using their medication. With the help of EHRs, doctors and patients have reliable, convenient access to all of this crucial information.
The American Health Information Management Association also stressed that EHRs help improve documentation integrity, causing physicians to focus on using the tools provided by the EHR system accurately. If these tools, such as smart phrases to assist with documentation, are not used appropriately, meaningful use standards will not be met and the integrity of the data may be questioned and considered inaccurate. In some cases, it could even be deemed as fraudulent activity. Therefore, the EHR system encourages the provider to review and edit all defaulted data as well as their electronic notes to ensure that the information is accurate.
Quality of clinical notes significantly improves
The Uniformed Services University of the Health Sciences in Maryland recently conducted a five-year study comparing the quality of electronic and handwritten notes taken during outpatient clinical visits. The study, published in the Journal of the American Medical Informatics Association, involved a total of 100 visits with patients who have Type 2 diabetes. The notes were evaluated six months before the physicians adopted an EHR system, again six moths after implementation, and then another five years after implementation. The researchers used an instrument called QNOTE to compare the differences in quality over the years.
The results showed that the note quality "significantly improved" over the course of the five years. There were even some that had noticeable differences in quality within the first six months following the adoption of the EHR system. The researchers noted that the most significant improvements were in past medical history, problem lists and social and family history. In core note quality – consisting of physical findings, follow up, plan of care and the patient's initial complaint – there was a 30 percent improvement.
Although the researchers did not focus in on the details of these improvements, they did comment on the benefits of the checkboxes that EHRs use to aid physicians in the documentation process. The researchers commented on the fact that EHRs are used for billing purposes, which greatly speeds up the process and makes it more efficient, but did not mention how this tied together with the improved quality of notes, according to Fierce EMR. They stressed that, to date, there is no set standard to analyze note quality, so physicians are not commonly provided with feedback regarding how they can improve their notes.