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Readers Write: What’s in YOUR Medical Record?

June 21, 2013 Readers Write 4 Comments

What’s in YOUR Medical Record?
By Ken Schafer

6-21-2013 8-07-36 PM

If my wife were admitted to the hospital with diabetic ketoacidosis (DKA), I’m pretty sure I wouldn’t want her electronic record to erroneously record a leg amputation (BKA). I’m equally confident that if this documentation mistake were made, I wouldn’t care too much how it happened. I would just want it fixed.

And if incorrect documentation on my diabetic wife resulted in an incorrect treatment course, which resulted in her death? You might end up with a $140 million verdict like this one.

Inga’s post on The Atlantic’s “The Drawbacks of Data-Driven Medicine” (from Big Datty,on 6/12/13) illustrates something that we all know to be true. Our medical records often contain mistakes, and electronic errors perpetuate themselves embarrassingly quickly. But her comments – and the source article – miss two very important points.

Doctors are responsible for the content of the records they create. This is true regardless of the method used to document patient encounters. Blaming the speech recognition system for hearing “DKA” instead of “BKA” makes no more sense than blaming a keyboard for a typographical error. If the physician picked the wrong checkbox on an EHR interface, would that be the fault of the EHR? Of course not.

Speech recognition, keyboarding, and dropdown menus are all methods for data capture. For that matter, so is a more traditional transcription process. But all of these methods have one element in common: the final content should be reviewed and validated by the documenting clinician. Physicians who fail to do this put their patients at risk.

Doctors make mistakes. I know a radiologist who dictated “liver” when he meant “heart.” The transcriptionist dutifully returned the report with the word “liver,” and it was signed by the physician. When the mistake was discovered, the audio was retrieved. The doctor listened to himself dictate the wrong organ, and blamed the transcriptionist. The point? Doctors are people, and people make mistakes, whether they own up to them or not.

That same physician was convinced speech recognition would eliminate transcription errors, and he was right – sort of. What speech recognition systems really do is eliminate transcriptionists, not errors. If radiologists are involved, there will still be errors. There’s no speech recognition system that will hear the word “liver” and change it to “heart.”

In fact, in our DKA:BKA example, the doctor may have had a bad day and actually said BKA to the speech recognition system. No matter what, though, the doctor made a mistake – either in what he said, or in what he saw on the screen and failed to correct.

Those with experience greater than mine often post to HIStalk about the shortcomings of EHRs in terms of the data they contain, with usability and completeness being favorite topics. My concern for our records is more specific. Especially when speech recognition is involved, what metrics do we have in place to make sure that narrative data is recorded accurately? If doctors are responsible for the content of their documents, and we know they make mistakes, how do we monitor and improve the quality of the narrative components of our EHRs?

As the government, physicians, patients, and the free market determine what systems we are to use and how they should work, we should never lose sight of this one truth: no matter what’s in the record, it should be right.

Ken Schafer is executive vice president, industry relations for

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Currently there are "4 comments" on this Article:

  1. … and we ought to do whatever we can to let patients see their medical records in an interactive medium and to play an active role in correcting them. Medical professionals are responsible for the accuracy of the record. But they (we) are far too slow to engage the skills of the most motivated record-reviewers ever.

  2. Speech recognition has not come of age for reliably accurate medical documentation, when lives depend on it.

    Even dictation/transcription is frought with error. Pen and paper or word processing by doctor is best, though even with spell check, the computer changes words to make no sense. The errors are increasing as EHRs automation propagates.

    To make matters worse, my doctors have no time to review the pages of legible gibberish for typos and other errors. Additionally, my doctors do not have time to debate with patients (their opinions) who might read a note that states they have depression and they deny it, or that they are non compliant with treatments.

    Also, on this, very funny, I have tried to get stuff deleted from EHRs of cases of my doctors, and it is darnn near impossible.

    Solution: let the reader be ware and all doctors should be skeptical of all they read from prior records.

  3. One of the new ONC 2014 Edition (stage2) test criteria is a system must allow for patient requested amendments to the EHR (170.314(d)(4). And the provider response and disposition of that request needs to be recorded as well.

    It would be very enlightening to know how often that issue occurs, but unfortunately ONC does not ask for a ‘numerator’ calculation of it, as it does for dozens of other MU criteria.

  4. Forget State 2 MU, Mr. Poggio! The 1996 HIPAA Privacy Rule allowed individuals to request health record amendments to analog and now digital records.

    Unfortunately, most patients don’t know they can ask to amend their records.

    Because, in many instances, patients are more in touch with their care than busy healthcare professionals, patients should be encouraged by providers to review their medical information for accuracy. Attention to these issues should be and, in many instances, is a priority for HIM, since the legal implications of any unintended consequences that come from faulty health record usage can be overwhelming (examples provided in the above article).

    Interacting with digital health record systems as a patient provides a different perspective and uncovers unique system flaws, which I have documented many times. (See Digital Information is Great, but Only if It’s Accurate; March 3, 2010 Mr.HIStalk Readers Write)

    Today, HIM Departments are experiencing more requests from patients to amend their medical records. That’s primarily due to increased access to patient portals, growing knowledge about the importance of maintaining one’s Personal Health Record, etc. Unfortunately, some facility HIM Departments have been fraught with amendment requests from patients who take offense that words that are construed as disparaging are being used in one’s records (e.g., “obese”).

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