Online ahead of print. Redundant information, which causes the inability to identify the current information; Inability to identify the author or intent of documentation; Inability to identify when the documentation was first created; Internally inconsistent progress notes; and. Kannry, Joseph. 2013 May;73(6):545-62. doi: 10.1007/s40265-013-0041-3. Poor EHR system design and improper use can cause EHR-related errors that jeopardize the integrity of the information in the EHR, leading to errors that endanger patient safety or decrease the quality of care. A “zero tolerance” policy on unethical copying practices should be adopted. American Health Information Management Association (AHIMA).  |  Impartial investigations should be conducted by an independent, federal entity, and in the spirit of transparency, investigative reports and results should be made public. There is no sense of shared accountability between system developers and users for product functioning.11 Adverse outcomes associated with EHRs are not being systematically and consistently tracked.12, It has been suggested that the introduction of HIT, rather than leading to improvements in the quality of data being recorded, has led to the recording of a greater quantity of bad data.13, 14 Although some of the studies cited in this article are several years old, recent literature continues to cite these studies. Wiysonge CS, Abdullahi LH, Ndze VN, Hussey GD. 2013 Dec;9(4):177-89. doi: 10.1097/PTS.0b013e3182a8c2b2. Public stewardship of private for-profit healthcare providers in low- and middle-income countries. “What It Will Take To Achieve The As-Yet-Unfulfilled Promises of Health Information Technology.”, Sittig, Dean F., and Hardeep Singh. A combination of federal government oversight and industry action is necessary to avert unintended consequences from EHR use. 2020 Jul 15;15(7):e0236019. Please enable it to take advantage of the complete set of features! National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error.  |  Sue Bowman, MJ, RHIA, CCS, FAHIMA. Healthcare organizations should ensure that all users receive thorough training on system use, including the organization’s expectations regarding the use of the system. Baillieu R, Hoang H, Sripipatana A, Nair S, Lin SC. To manage information assets and ensure appropriate decision-making, healthcare organizations (including providers, policy makers, and vendors) should deploy information governance concepts and programs. Strategies to address EHR usability problems and reduce improper system use include the following: Recommendations for improving EHR documentation creation include the following: As noted above, in order to promote the quality and safety of clinical decision support systems, the risk of patient harm associated with a specific application should be systematically assessed, and quality and safety procedures that are proportional in stringency to the identified clinical risk should be adopted.124 Since risks cannot be eliminated entirely, the goal should be to implement processes that minimize avoidable patient harm and manage known but unavoidable safety hazards.125 For example, safe organizational practices and cultures should be established,126 including training users properly, establishing a working environment that is conducive to safe practices, and ensuring that the decision support system is appropriate for the clinical tasks for which it is being used.127. For example, a structured data field may indicate that one pill should be taken twice a day, while the free-text instruction field says to take two pills in the morning and one pill in the evening.37 Other errors can be caused by inconsistent drug dosing and missing information.38, Clinicians increasingly share control of complex processes with computers; in some instances, they assume a higher-level oversight role and allow computers to make routine decisions and carry out appropriate actions (e.g., the computer automatically generates a laboratory order when certain medications are ordered).39 Although EHR systems do not directly impact patient care without human intervention, this technology is often so complicated that users are unable to analyze or understand its computations and therefore cannot exercise competent human intervention.40 For example, clinicians may rely on computer-generated diagnoses and treatment recommendations without fully understanding how the algorithm was developed or that the algorithm did not take into account certain medical conditions or clinical factors that are relevant to the patient at hand. Weir, C. R., et al. “Medical Malpractice Liability in the Age of Electronic Health Records.”, Botsis, Taxiarchis, et al. As discussed previously, concerns with the integrity of information in EHRs continue to rise. L. Poissant, J. Pereira, R. Tamblyn, Y. KawasumiThe impact of electronic health records on time efficiency of physicians and nurses: a systematic review. Strategies for EHR implementation should be therefore recommended and promoted. “E-Health Hazards: Provider Liability and Electronic Health Record Systems.”, Mamykina, Lena, et al. “Physicians’ Attitudes Towards Copy and Pasting in Electronic Note Writing.”. AHIMA. Clipboard, Search History, and several other advanced features are temporarily unavailable. No comprehensive study has been conducted to determine the industrywide incidence of EHR-related errors or adverse clinical events resulting from these errors. Source attribution for copied text should be required. Further research is also needed on the causes of EHR-related errors and on effective strategies for preventing and correcting them. doi: 10.1136/amiajnl-2012-001458. “Computer Decision Support as a Source of Interpretation Error: The Case of Electrocardiograms.”, Strom, Brian L., and Rita Schinnar. “E-Health Hazards: Provider Liability and Electronic Health Record Systems,” 1580. COVID-19 is an emerging, rapidly evolving situation. Methods: PubMed, Web of Knowledge, Scopus and Cochrane Library databases were searched to identify studies that investigated the association between the EHR implementation and process or outcome indicators. 2020 Sep 18;28(1):50. doi: 10.1186/s12998-020-00339-0. A study of records in the Veterans Health Administration’s EHR system found that 84 percent of progress notes contained at least one documentation error, with an average of 7.8 documentation errors per patient.50 Types of errors included copied text, incomplete or inaccurate templates, documentation entered in the wrong patient’s medical record, inconsistent text, and outdated embedded objects.51 Although this study was published 10 years ago, more recent studies are consistent with these findings. data integrity; electronic health records; health information technology. Kloss, Linda. Phillips, Win, and David Fleming. Intention to use electronic medical record and its predictors among health care providers at referral hospitals, north-West Ethiopia, 2019: using unified theory of acceptance and use technology 2(UTAUT2) model. doi: 10.5001/omj.2020.85. Get the latest public health information from CDC: https://www.coronavirus.gov. 2020 Oct 1;71(10):1065-1068. doi: 10.1176/appi.ps.201900470. Additional types of user-related errors resulting from improper documentation capture can be found in Appendix A. Meta-analysis showed an association between EHR use and a reduced documentation time with a difference in mean of -22.4% [95% confidence interval (CI) = -38.8 to -6.0%; P < 0.007]. Information technology is transforming the world from the large volumes of files in the offices to a paper free environment and health care sector is not left behind given the advantages attached to this technology. Siegler, Eugenia, and Ronald Adelman. Sue Bowman, MJ, RHIA, CCS, FAHIMA, is the senior director of coding policy and compliance at AHIMA in Chicago, IL. Keywords: electronic health records; health information technology; data integrity, US health spending far surpasses that of other countries, yet our healthcare system fails to regularly deliver high-quality healthcare.1 The quality of healthcare across the continuum depends on the integrity, reliability, and accuracy of health information.2 Adoption of health information technology (HIT), including electronic health records (EHRs), is essential for the transformation of the current US healthcare system into one that is more efficient, is safer, and consistently delivers high-quality care.3 (In this article, the terms HIT and EHR are used interchangeably and include electronic prescribing and clinical decision support. Migrating to electronic health record systems: A comparative study between the United States and the United Kingdom. EHR content standards should be defined, which would enhance efficiency, reduce redundancy, alleviate the documentation burden, and improve integrity. “EHRs: ‘Sloppy and Paste’ Endures Despite Patient Safety Risk.”, O’Malley, Ann S. “Are Electronic Medical Records Helpful for Care Coordination?”, Thornton, J. Daryl, et al. doi: 10.1097/MD.0000000000021182. “Impact of Electronic Health Record Systems on Information Integrity: Quality and Safety Implications.” Perspectives in Health Information Management (Fall 2013): 1-19. Nuckols TK, Smith-Spangler C, Morton SC, Asch SM, Patel VM, Anderson LJ, Deichsel EL, Shekelle PG. Methods: A study assessing the effect that computer interpretation of electrocardiograms (EKGs) had on the accuracy of internal medicine residents’ EKG interpretations demonstrated that physicians are significantly influenced by incorrect computer interpretations.83 The residents documented an incorrect EKG interpretation almost twice as often when they were provided with an incorrect computer interpretation than when they received no computer assistance.84 The results of this study are a clear example of automation bias, whereby physicians tended to follow the computer’s advice even when it was incorrect. Middleton B, Bloomrosen M, Dente MA, Hashmat B, Koppel R, Overhage JM, Payne TH, Rosenbloom ST, Weaver C, Zhang J; American Medical Informatics Association.

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