This guide to electronic health record basics isn't rocket science, but it's required reading for healthcare IT pros.
It's easy to overlook simple, commonsense solutions to health IT problems, looking instead for "rocket science" fixes. The Agency for Healthcare Research and Quality's best practices for avoiding electronic health record (EHR) snafus doesn't require an advanced degree in computer science, and every healthcare IT manager should give it a read.
For instance, AHRQ's guide emphasizes the importance of having a clearly defined copy and paste policy so that healthcare providers don't inadvertently duplicate misinformation or open up the organization to lawsuits.
During InformationWeek Healthcare's recent IT Leadership Forum, Yale New Haven Hospital's Charles Lockwood, MD, warned about the risks when clinicians copy a section of yesterday's clinical notes into today's notes because the patient is presenting with the same set of signs and symptoms. One obvious risk, of course, is that factual errors are repeated.
But there are other risks. Suppose a clinician in the emergency department treats a laceration with sutures and includes a complete history, physical exam, and system evaluation as part of his workup. Then the patient comes back in 10 days for a follow-up exam. What often happens is the clinician looks back at his previous EHR entry and simply copies and pastes his previous notes for the second visit--despite the fact that no history and physical were actually done the second time around.
What may happen next is the medical coding clerk picks up the details from the second visit and puts in a request for reimbursement at the higher level of care provided during the first visit--unwittingly committing medical fraud. The take-home message is obvious: Everyone entering data must be meticulous about what they duplicate.
Another no-brainer covered in the AHRQ database: "Prevent data entry staff from being distracted." Establishing a policy that keeps it relatively quiet in their work area, and enforcing that policy with posted reminders, are simple steps that can help prevent serious mistakes.
Another valuable piece of advice: If your facility recently experienced a serious medication error, it's probably time to do an in-depth review of your computerized physician order entry (CPOE) system to find vulnerabilities.
In some cases, the fix may be something as simple as limiting a physician's choices in the CPOE by replacing a free text box with a menu that lists specific drug names, dosages, and patient variables. In other cases, it may be necessary to tweak the system so that physicians can't navigate away from a critical data field that needs to be filled in.
AHRQ's "Guide to Reducing Unintended Consequences of Electronic Health Records may not be a page turner, but it's must reading for every healthcare IT manager who takes patient safety seriously.