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EHR Documentation – Don’t Forget The Patient

Alongside the drive for efficient file sharing and comprehensive health records to support patient care, there is growing concern that the most critical element in the care equation – the patient – may be at greater risk as most providers shift toward EHRs.

Proper patient care is at risk

EHR Patient Care
Evidence is mounting that physicians distracted by digital tasks like entering data during a consultation, divert critical focus away from observations of body language, subtle tonal changes and environmental signals necessary to accurately assess health status and patient comprehension.
Risks associated with converting patient data to EHRs are two-fold. On the one hand, patients are not getting the undivided attention they deserve and need to ensure appropriate treatment. On the other hand, inaccurate records could result in increased denials and lost revenue for providers. Potential problems may include but are not limited to:

  • Inaccurate patient records
  • Coding errors that result in reduced, delayed or denied reimbursements
  • Misdiagnosis
  • Failure to prescribe appropriate prescriptions, therapy, or treatment guidelines

According to research published in the Annals of Internal Medicine, overcoming the risks associated with “distracted doctoring” is possible with a balanced approach. Each practice should design a balanced approach that works to improve outcomes for the patient and the physicians. Many practices opt to use medical scribes (remote and in-person) that take pressure off the physician and allow them to focus more on the patient.

Steps Physicians Can Take To Avoid Distracted Doctoring

  • Choose scalable EHR software solutions designed for physician practices that are easily modified to accommodate specialties and treatment protocols
  • Update drop down menus to reflect accurate diagnoses rather than settling for a similar option
  • Create check boxes for new diagnoses or increased specificity
  • Designate clinical staff members to document visit details based on physician observations and patient comments
  • Regardless of how data acquisition, patient record updates, and clinical notes are managed, physicians should confirm EHR information with the patient and check for comprehension before ending the visit

Managing electronic health records is imperative for medical practitioners and patients. Maintaining accurate billing records reduces financial risks for providers and protects patients from unnecessary risks associated with errors and omissions that lead to misdiagnosis and inappropriate treatment plans.

One solution to improve EHR management is to choose an automated EHR system that operates across multiple platforms, integrates fully with web-based and on-site automated systems, and is flexible enough to adapt to changes within the practice.

Issues during the pandemic

As we’ve established, proper and accurate EHR documentation can only occur when physicians are able to focus wholly on their patients, either relying on scribes or themselves to document health issues. Since hospitals and doctors are overwhelmed with the sheer amount of coronavirus cases, understandably they are burnt out and drawn all over the place. It is most likely that EMR and EHR documentation will face less detail and more error-options, a Physician News article mentions.

In addition, hospitals are more likely to bring more people on board in an attempt to reduce the workload on existing practitioners. Staffing records will begin to show more “agency nurses, unretired health care providers and volunteers” who may not be very familiar with EMR and the necessary knowledge to properly document EMR and EHR.

Nation-wide EHR and EMR systems will face the test of grappling with COVID-19 patient information in many ways.

  1. Functionality and usability – Systems will take longer to retrieve patient health information with the abundance of information that comes with health records being pulled up, concealing potential patient risk
  2. Rapid updates – The increased number of threats regarding COVID-19 patient health information. Frequent updates will ensure proper fortification of PHI as well as incorporate more updated EHR information for physicians to use.
  3. Interoperability – Data sharing between systems and platforms are crucial to share research and observations for a new disease that the world continues to grapple with.

Overview of PracticeSuite Medical Billing Software

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