Just as with any other type of record that requires information to be entered manually, medical records are bound to contain errors. A recent Patient Engagement HIT article breaks down how patients are becoming a driver of recognizing and requesting fixes for errors in the EHR. While medical records are prone to standard typographic errors, they also have issues that tend to be more unique to healthcare like incomplete results, duplicate records, and copy/pasted text that can perpetuate errors.
With 20% of patients finding an error in their care notes (and 40% of that group believing that the error was serious), this is a significant problem. The importance is only increased by the magnitude of potential consequences, which are much more dire in healthcare than elsewhere.
Healthcare also faces the problem of attempting to create a profile of a patient whose documentation is spread through different geographies, times, and software platforms. It’s certainly easier to ingest information about a patient now than it used to be. Through a combination of legislation and technological advances, healthcare data is more accessible to patients and moves between organizations more easily.
Mandates surrounding information blocking in the 21st Century Cures Act have allowed patients easier access to their medical data, and who better to spot an error than the patient themselves? This doesn’t mean, however, that as a patient I can insist to my physician that my medical record should list my height at ‘six feet’ or my eye color as ‘captivating.’ It does mean that I can raise an issue regarding an incorrect allergy or part of my medical history.
Another study in the article showed that 85 percent of respondents were satisfied with the resolution they received after flagging a medical error. Regardless of whether those patients flagging an error received clarification regarding the information or a correction was made, members of that group are more satisfied or have better documentation in their chart.
Patients have differing levels of comfort and interest in spotting errors in their medical records, so clinicians and leadership would do well to find ways of engaging them to uncover any issues that could be consequential.
Rather than correct errors, it’s obviously better to not have them to begin with, and the march toward interoperability and increased prevalence of interfaces has helped us come a long way. An interface between a hospital and a laboratory can ensure that results for a patient are complete, matched, in the correct units, etc. but require extensive setup and maintenance investments, which leads to diminishing returns with lower volume partners.
Until we see the adoption and implementation of universal interoperability standards, some level of incoming documentation will require intervention. This triage process can be minimal, classifying incoming documents and indexing them to the correct patient. It’s even a process that can be fully automated with our software or others available on the market.
In order to abstract discrete values into a patient’s record for tracking and trending, you’ll need a skilled data entry staff and a more advanced technology that can keep up with your document inflows. Automated data extraction software can use information obtained from classification and indexing to identify and deliver the relevant discrete data to a patient’s medical record. This process works best when using some members of your knowledgeable staff to verify captured data while others are freed for higher value tasks thanks to the automation.
Where possible, it’s always best if data can be entered completely, singularly, and accurately. Data interfaces and automation software can reduce both the burden of entry and the opportunity for mistakes. Medical records will inevitably have some mistakes and a process for finding them should involve both engaged patients and clinicians (or software) that can spot and question an anomaly.
As a mutually beneficial process for both patients and providers, error identification and resolution can be an important part of building lasting trust and providing the best possible outcomes. If you’re struggling to get complete, accurate, or timely information from your non-interfaced documents, please reach out and we’d be happy to explain more or show you a demonstration of our software.
About the Author: Chris Mack
Chris is a Marketing Manager at Extract with experience in product development, data analysis, and both traditional and digital marketing. Chris received his bachelor’s degree in English from Bucknell University and has an MBA from the University of Notre Dame. A passionate marketer, Chris strives to make complex ideas more accessible to those around him in a compelling way.