Tara Philcox

 

The Problem

The ongoing debate in America about health insurance coverage shows how healthcare costs have climbed globally. In his recent article titled "Health information exchanges reduce redundant medical procedures," Jack Karsten reveals that the United States of America spends a higher share of the Gross Domestic Product (GDP) on health care than other nation. Still, its health care outcomes underperform those same nations (Karsten, 2017). Most of this ineffectiveness is caused by the redundancy in medical documentation due to the Electronic Medical Records (EMR). According to Karsten (2017), the “Congressional Budget Office estimates the cost of procedures that did not improve health outcomes at $700 billion per year.” This article will explain redundancy in medical documentation due to EMR, propose solutions and offer recommendations to improve patient outcomes and benefit nursing.

Examples

Redundancy in medical documentation due to electronic medical records is associated with several problems: copy/paste practice or cloning problems, patient identification errors, authorship integrity issues, dictation errors without validation, audit integrity, and healthcare abuse and fraud (Murphy, 2017). Cloned documentation or copy/paste practice continues to be a major problem in my facility that creates inaccurate information and unnecessary redundancy in the electronic medical records. If not modified to be pertinent to the visit and patient-specific, automated insertion of outdated or previous information via electronic medical tools may raise significant compliance and quality of care concerns. This has the potential to lead to medical liability issues.  But with the providers wanting to see clients quickly, it is hard to get them to change their ways.

The other significant challenge caused by redundancy in medical documentation due to electronic medical records is patient identification errors. The integrity of documentation is at risk when administrators enter the wrong or inaccurate data on a wrong patient health record.  I frequently have to edit charts due to the wrong information uploaded to a patient chart, this exposes us often to HIPAA violations. Errors in patient identification may affect patient safety, clinical decision making and impact a patient's security and privacy (“Cures for Note Bloat," 2020). It can also lead to increased costs to payers and patient providers and duplicate in testing. Patient identification errors can grow within the electronic medical record networks as the data proliferates. When health care systems fail to put a validation step when using voice recognition, they are likely to experience significant administrator documentation errors and data quality problems. Authorship attributes the creation or origin of a specific unit of data to a particular entity or patient acting at a given time. When there is more than one editor or administrator to a document, it may not be easy to verify each service provider's amount of work or the actual service provider.

The other problem caused by redundancy in documentation due to electronic medical records is the challenge of healthcare abuse and fraud. Healthcare fraud means the intentional misrepresentation or deception that the entity or a person makes, knowing very well that the deception or misrepresentation may lead to some unauthorized benefit to the entity, party, or individual (Murphy, 2017). The intentional fabrication of medical data to improve reimbursement is considered a healthcare fraud. Fabrication can be caused by the misuse of templates designed to boost documentation efficiency and the overuse of copy/paste practices. On the other hand, health care abuse refers to practices or incidents that are not consistent with accepted business or medical practices. These unintentional incidents or practices may involve coding errors or repeated billing.

Audit integrity is another significant problem caused by redundancy in medical documentation due to electronic medical records. Regular audits are important in ensuring only authorized users are making entries or accessing patient medical records (“Cures for Note Bloat," 2020). Electronic medical records that lack robust audit trail functionality may create legal liability for medical service providers or uncertainty in the integrity or reliability of health record documentation. This may also make it impossible for health care facilities to determine when and if amendments or corrections were made to patient health records, the nature of the changes, or the individual who made the changes. This is a huge issue at my facility.

The Solution?

The remedies or solutions that can be taken to improve the problem of redundancy in medical documentation due to the electronic medical record fall into two categories which are administrative and technical.  Administrative solutions require health care facilities to establish practices that support quality clinical documentation such as implementing policies and using procedures and system capabilities and functions to prevent fraud, commitment and desire to provide health care ethically and the inclusion of a Health Information Management (HIM) professional, for example, an electronic medical record team or a record content expert to ensure the final product is compliant with all coding, billing, regulatory, payer guidelines and documentation (“Cures for Note Bloat," 2020). Policies must include patient identity programs such as performance improvement measurements to monitor the percentage of duplicate records and error rates within the specific electronic master patient index. Innovations are also needed to improve documentation techniques and tools. Each hospital staff has the responsibility to identify and prevent healthcare abuse and fraud, and they must be held accountable in case any misrepresentation occurs. The procedures and policies should ensure that demographic data are used to link records across and within systems and the data is accurate. The technical solutions call for capabilities in electronic medical record technology that require user access management and authentication. This will restrict alterations to auditing files and make it possible to track user activities, including audit logs (Murphy, 2017).

To solve the problems associated with clinical documentation, hybrid protocols, and a pure NLP protocol should be used because they show promise for electronic medical record documentation than Standard Entry alone. Natural language processing is another key component that can ease EMR documentation burdens if used with better technologies (Murphy, 2017). Organizations should also educate and train their staff members to ensure they are well-informed about legal and compliance risks. The education program must be maintained, monitored, and offered annually or quarterly. A combination of technical and administrative solutions will ensure the electronic medical records benefits all the stakeholders involved.

What Can We Hope to Expect?

The changes will significantly improve patient outcomes and benefit nursing by improving all aspects of health care, including effectiveness, safety, patient-centeredness, education, efficiency, communication, equity, and timeliness. The changes will also lower health care costs through reduced duplication of testing and improve coordination in the healthcare system and provide up-to-date, complete, and accurate information concerning patients. It will also allow quick access and securely sharing of information between patients and health care practitioners. Time is critical in nursing because nurses are often overloaded with activities and tasks; the changes will therefore help them save time. The other benefits that the changes will bring include improved caregivers' satisfaction and productivity by worrying less about documentation and administrational activities and concentrating on their clinical activities. Customizing electronic medical records based on caregiver's demands will increase their efficiency and increase patient safety and decrease errors. Electronic medical records can, without doubt, improve health worker efficiency and improve patient care if the problem of redundancy is eliminated.

 

References

Cures for Note Bloat. (2020, October 6). Foresee Medical. Retrieved from: https://www.foreseemed.com/blog/note-bloat-cures

Karsten, J. (2017, May 26). “Health information exchanges reduce redundant medical procedures.” Brookings. Retrieved from: https://www.google.com/amp/s/www.brookings.edu/blog/techtank/2017/05/26/health-information-exchanges-reduce-redundant-medical-procedures/amp/

Murphy, K. (2017, February 24). “Improving Clinical Data Integrity through HER Documentation.” Intelligent Healthcare Media. Retrieved from: https://www.google.com/amp/s/ehrintelligence.com/features/amp/improving-achieving-data-integrity-through-ehr-documentation