Improving EHR Formatting and Data Entry can Address Patient Safety Concerns

Improving EHR Formatting and Data Entry can Address Patient Safety Concerns

Industry

experts

say

that

improving

the

formatting and data entry capabilities of EHRs can improve patient safety.

MTS Transcription Services United States

Physicians and the medical transcription companies that help them with their clinical documentation are well aware of the impact of electronic health record (EHR) data entry errors on patient safety. A recent report from the ECRI Institute highlights these issues.

According to this organization, which researches approaches to improving care, EHR management is the topmost patient safety concern today. The HIMSS Electronic Health Record Association (EHRA) says that simple formatting and data entry modifications can take care of EHR documentation errors that compromise patient safety.

Patient Safety: EHRA Recommendations to Improve EHR Design The report makes recommendations for the most effective use of display design techniques and elements in five areas: •

Medications

•

Alert Fatigue

•

Lab Results

•

Numeric Display

•

Displaying Text

Medications: Errors in medication names have serious implications for patient safety.

EHRs need to be designed to display medication information in a way that improves safety in medication ordering, administration, and dispensing. The report recommends that EHRs should store medication names in a way that is case-sensitive and can support tall man letters. The use of Tall Man letters has been recommended by the ISMP, the Food and Drug Administration (FDA), The Joint Commission, and other safety-focused organizations as a means of reducing confusion between drugs with similar names.

For example, acetazolamide and acetohexamide can be confusing. On the other hand, using tall man letter can distinguish these drugs from each other: acetaZOLAMIDE and acetoHEXAMIDE. If drug name, strength, dosage form, and dosage units appear together, putting a space between them can avoid mix-ups.

Alert Fatigue: It often happens that providers ignore safety alerts and fail to respond to them appropriately. The report recommends providing simple and clear alerts so that clinicians will notice important warnings. EHRS should differentiate alerts based on importance such as low, medium and high, based on the severity of potential harm to the patient. Visual (for instance, colours), spatial, or other differentiators should be used to distinguish critical and non-critical situations.

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Laboratory Results: EHRs design for lab results should be displayed in a way that providers can easily and quickly distinguish abnormal results. Clinical laboratory results may include numeric values or text-based results and these should be displayed clearly.

This will improve the clinician’s ability to respond to them correctly. For instance, results that are outside of the range are critical, whether they are outside of a reference range individually or show an abnormal variation from previous test results. The report recommends: -

Keeping multi-component test results together when they are displaying along with other results

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Displaying values in wide columns so that users do not have to adjust display

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Having all information needed to make a clinical judgment on the same page and visible without scrolling

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Clearly distinguishing new results from previous results

Numeric values: There is also special stress on decimals and commas. As EHRs contain a wide array of numerical formats, consistent use of decimals and commas is necessary to prevent misinterpretation of a medication dosage. For example, .5 mg can be misread as “five milligrams�. More clarity can be obtained by reformatting to 0.5 mg.

A comma should be used to separate a number with 4 digits indicating a dose. For instance: Dose: 1,000 units in lieu of Dose: 1000 Text display and layout:

The report recommends strategies to minimize or eliminate

truncated data in EHRs. It recommends that table cells should be wide enough to display complete entries as truncated information can be confusing. This is especially relevant for medication names.

Medical transcription service providers take great efforts to provide physicians with accurate EHR-integrated documentation solutions that enhance the quality of patient care. Improving EHR formatting and data entry will improve the integrity of medical data and allow these dedicated documentation specialists to serve clinicians better.

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