ize software and the operational realities of fast-paced medical
Working outside the System
Other pitfalls come when practices disable, ignore, or do not use
systems in a way that can improve care. For example, while observing the care process in one practice, Drury noted that at the
end of an examination the physician gave the patient a handwritten paper prescription. Asked when he intended to record
the prescription in the EHR, the physician indicated he would
do so that evening.
Drury saw a series of potential concerns with this scenario.
The electronic record would have been incomplete in the event
the patient had a reaction to the medication that afternoon. In
addition, the handwritten prescription created the opportunity
for the pharmacist who dispensed it to make a dosage or drug
error, and if he or she had contacted the practice for verification
there would have been nothing in the chart to go by. Finally, the
physician did not take advantage of the software’s drug safety
module, which checks for adverse drug reactions.
Other system configurations may allow information that was
in the system to be removed without notation.
Drury cites the experience of one practice in which the nurse
spoke with a patient about a health issue, documented her understanding of and recommendations regarding it, and forwarded these electronically to the physician. The physician agreed
with her proposed response; however, he deleted his part of
the message endorsing the plan, eliminating evidence that he
provided appropriate care oversight. This particular glitch was
solved by restricting deletion privileges for the physician.
These examples are just the tip of the iceberg, Drury says.
“Those things are happening by the gazillions and we don’t
know about them,” she contends.
Education Is the Cure
Drury has found that often staff are not aware of the potential
risks or actual problems with how they configure and use their
EHR systems. However, she believes there is a great opportunity
for HIM professionals to correct misuse and address less-than-ideal functionalities.
Often the person in the practice who deals with EHR issues
has little in-depth training on its optimal use, she says. They may
lack HIM education. But if trained, they can spearhead better
practices and drill into the EHR and recommend changes.
In addition, Drury encourages HIM professionals to look at the
EHR analytically, as if they were outsiders assessing it on behalf
of a professional liability insurer. The questions to ask include:
HIM professionals also will do well to familiarize themselves
with Health Level Seven’s EHR System Records Management
and Evidentiary Support Functional Profile, Drury says. This in-
dustry standard describes the attributes that support the man-
agement of health records within the system for business and
Genna Rollins ( email@example.com) is a freelance writer specializing
First Class Solutions, Inc.SM
Not your traditional healthcare consulting firm…
Services customized to YOUR needs since 1988
Our HIM Services
♦ Temporary HIM Management Services
♦ RAC and MIC Readiness Reviews
♦ Operational Assessments
♦ ICD- 10 Preparation
♦ Coding Validation Audits and Coding Support
Our Specialized HIM Software
CORTRAK®: Release of Information tracking
system includes disclosure accounting, invoicing,
; Available using Microsoft® SQL Server
(CORTRAK Plus) and Document Scanning
AUDIT-TRACKER®: Audit Process Management
& Tracking for Internal & External Audits
; Facilitates tracking Requests, Denials, Appeals and
Take-backs; Includes sample letters; Import, scan
and store all documents related to the audit;
Team/task assignments; User defined timeframes,
appeal levels, and email notifications; Real time
dashboard highlights overdue actions, financial
impact, and more