Electronic health records have the potential to streamline data entry and improve accuracy. But they’re also a relatively new technology for health systems, which can be the cause of costly and dangerous mistakes. As a healthcare provider, make sure you are taking the necessary steps to reduce data entry errors in EHRs.
The cost of data entry errors
A 47-year old man with advanced AIDS is admitted to an academic medical center complaining of shortness of breath. He is diagnosed with pneumonia, but the physical examination also reveals two lesions that make the medical team concerned about Kaposi’s sarcoma and HPV infection. After consulting the dermatology service, they perform biopsies of both lesions.
Three days later, the patient is recovering from pneumonia when his primary care doctor visits. The doctor examines the patient’s medical record before the meeting. The EHR lists three biopsy results for three lesions, all showing different types of cancerous cells: one sarcoma and two carcinomas. Given the patient’s end-stage AIDS and these three diagnoses, the primary care doctor meets with the patient and recommends hospice care.
However, later that afternoon the inpatient’s medical team recognizes an error. The third biopsy was performed on another patient and accidentally entered into this patient’s medical record. The team and the primary care doctor all meet with the patient to disclose the mistake, but only after he had experienced extreme pain and mental anguish.
As this real case suggests, data entry errors like patient identification mix-ups are a serious risk when using EHRs. Unfortunately, many patients and providers aren’t as fortunate as this case from dermatology. EHRs are often the culprit in medical errors that impact patient safety, and many patients and providers only learn of an error after adverse outcomes much later in the treatment process. According to a recent study, the most common malpractice claims filed in relation to health IT were about errors involving medication (31%), treatment complications (31%) or diagnoses (28%).
How to reduce data entry errors in EHRs
In 2019, nearly every US hospital is using EHRs. On the whole, providers know that electronic records should improve the efficiency and accuracy of medical data entry. Here are five ways to make EHRs a time saver instead of a data entry nightmare.
1) Automate data entry
As a modern physician you have access to tools and software solutions that automatically send information from physiological monitors to a patient’s chart. This means that it’s possible to eliminate errors when entering data like blood pressure, temperature, weight and pulse oximetry. Automating this type of routine data entry saves time and eliminates errors from one stage of the medical visit.
2) Use templates
All the newest EHR software products allow for some level of customization with specialized templates suitable for your practice. An EHR template stores relevant data fields so nothing is missed, while making important information easy to access through intuitive screen layouts and menu commands. Using templates is a good way to reduce data entry errors in EHRs.
3) Create evidence-based order sets
An order set is a collection of pre-formed orders used to manage a disease state or a specific procedure. You can set up order sets in advance for common medications, diagnostic tests, procedures or conditions. This is a great way to reduce medical errors, develop a safer healthcare environment, improve outcomes and streamline clinical workflow.
4) Adopt smart dictation solutions
While it may seem counterintuitive, some clinics are using the latest voice recognition software to reduce errors in data entry. Using the right dictation solution can help you speed data entry, improve turnaround and reduce errors associated with poor handwriting. Direct EHR speech-to-text allows users to instantly review their dictation to ensure accuracy.
5) Implement patient portals
One of the simplest ways to reduce data entry errors in EHRs is to set up a patient portal. If patients can access a portal and enter some of their own data, the medical team only has to confirm the information’s accuracy. Make sure you are using all the tools available to reduce data entry time and confirm the accuracy of patient data.