Would you give your patients a rotten loaf of bread?
No you wouldn’t!! Sure some of the pieces of the loaf may look fine, but mold and bacteria would probably make them sick to their stomach and give them an unplanned colon cleansing.
Nor would you give your patients inaccurate and hard-to-read medical documentation about their care that can lead to misdiagnosis, poor care, and improper billing. But that is what we in the medical industry are doing every day whenever we participate in EHR group-think and pretend that all is well since “everyone else is doing it” or “I don’t have much of a choice since this this is the system we use”.
There’s way too many rotten apples in the document integrity “barrel”. But as professionals, we must not only diagnose our patients properly, we must also diagnose our flawed systems and compel our organizations to fix them.
Several professional organizations like ACDIS, ADHI, AHIMA, and ECRI agree that an adversary to improved healthcare is the current functionality and credibility of the EHR. Faulty EHR documentation increases the probability of undermined patient care. ECRI has called the persistent Document Integrity degradation the #1 enemy to patient safety for 2017. We sarcastically call it Document “Integridation”.
Want to know ECRI Institute’s #1 Concern for
Healthcare Organizations in 2017? It is:
Information Management in the EHRs
Dr. Reed Gelzer, MD, MPH, of Trustworthy EHR, a nationally recognized quality and information integrity consultant specializing in the legal aspects of EMRs, offers the following observations* about Providers:
- They use functions that result in authorship falsification
- They disable audit functions
- Document misattribution that have (potentially material) legal implications
“People will do things in an EMR record
that they would never do in a paper record.” *
Dr. Reed Gelzer, MD, MPH
Whether it is lagging communication between providers and IT, mismanaged electronic document control, copy-paste errors and data-duplication, shared and compromised record authorship, or a liberal audit control authority – to name a few – the time has come to comprehensively employ policies, systems, technology, and appropriate transcription and coding functions that aspire to eliminate material EHR errors, towards improved patient care.
To read our exclusive White Paper entitled, “The Emerging Role of Medical Transcription in the Electronic Health Record”, independently authored by Darice Grzybowski of H.I.Mentors™ – a nationally renowned author, speaker and Thought Leader in the field of medical health documentation, processes, and systems – click HERE to get your FREE copy. You won’t want to miss Grzybowski’s 5-point Conclusion and Recommendations!
* https://www.ahcmedia.com/articles/117213-data-integrity-failures-in-emrs-is-no-1-concern
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With iD3, iData is entering a new phase in medical documentation thought leadership.