Guest Post: Be wary of EHR ills

by Darice M. Grzybowski, MA, RHIA, FAHIMA

I was recently discussing the state of EHRs in regard to the poor quality of the documentation with a colleague who has been a practicing HIM professional for more than 35 years and currently works for a large group of hospitals as the coding director. She expressed great concern about how the documentation no longer tells the story of the patient in a clear way. And, she wanted to know, why more isn’t being done to remedy the problem.

To fix any problem, one must understand why or how it occurred. Obviously clinicians don’t try to create worthless, redundant, and conflicting documentation. Vendors don’t try to develop systems that are poorly designed and which may lead to errors in interpretation, redundant notes, and impossible to read printed formats. Most poor documentation problems are unintentional and occur because vendors lack an understanding of how to develop a properly formatted, output-based, episodic-driven medical record.

Another concern is that problematic technology enables poor documentation habits. I was recently told by an EHR vendor that they purposely designed options where information from historical labs could be pre-populated into current history and physicals (H&P) and progress notes as an efficiency measure.

The beauty of electronic documentation is that users should be able to see existing lab values, historical problems, or medications without copying it into a note. The problem of pushing forward old information, either within a visit, from a previous visit, or upon request of a clinician, is wasteful and at times dangerous when the reader of the note may mistakenly interpret an old lab value as a current one.

The following examples illustrate the dangers associated with technology that enables poor documentation habits:

• Allowing copy and paste continues to cause note bloat in the printed format as well as electronic. When printing these records, the poor formatting makes it nearly impossible to interpret the documented values. And yes, the majority of medical records are printed in one way or the other for various reviews and release of information just so that someone can look at a complete record without flipping endlessly through fragmented screen templates. This is often a surprise to most of the clinicians and information technology staff who are later shocked when budgets for paper and toner are continuing to increase.
• Inappropriate EHR functionality such as “sign all” allows providers to authenticate orders and reports, which often results in signing off on clinical documentation queries without actually reading them. This type of functionality allows ill-designed system proliferation of burst-apart standing orders to continue, rather than be identified and corrected. Adding further functionality of automatic release of such documents then creates proliferation of duplicative notes and orders to other facilities and practitioners.

Editor’s Note: Grzybowski, at the time of this article's original release, was the president of HIMentors, LLC, and the 2015 recipient of the AHIMA Triumph Award for Literary Legacy. For informatino, visit her website www.HIMentors.com or email info@HIMentors.com. This article originally appeared in the October edition of Medical Records Briefings.