EHR and Its Effect On Ethical Decision Making In Your Practice

There’s no denying the impact electronic health records (EHR) have on your practice. Between the helpful and the complicated features in EHRs, we’re sure your physicians have developed mixed feelings.

Despite the benefits and difficulties of EHRs, there is a greater ethical impact they may have on your practice. When not used correctly, EHR documentation can lead to lapses in clinical—and even legal—judgment in your practice.

We want to help protect your physicians, nurses, patients ,and more from ethical EHR errors. To begin, follow along with us below to discuss the five potential areas in which your practice may be experiencing flaws in clinical judgment due to EHR. Then continue reading to understand how a medical transcription service can positively impact ethical issues in your practice.

5 Ways EHR Impacts Clinical Judgment Within Your Practice

1. False EHR Data Input

Because of the lengthy documentation and ttime-consumingadministrative work, it’s easy to try to cut corners with EHR.

For example, when a physician sees a patient, they may forget to check a box or record certain information. Instead of being truthful about the mishap, they may feel the need to check the box and mark the task as completed. While this might temporarily fix the problem, your team may experience issues in the long term with proper patient care.

The issue with copy and paste

Since EHR form fills can sometimes be redundant, medical staff may feel the need to copy and paste old information. This copy-and-paste feature has caused quite a debate in the medical industry. Physicians feel that the ability to copy, paste, clone, or replicate data is essential to saving valuable time. On the other hand, this could lead to inaccurate documentation of patient information.

Relying on copying and pasting information can negatively affect patient care. This happens when old or outdated patient information is transferred into new documents. For example, a physician may be seeing old symptoms, treatments, and care information that isn’t relevant to the patient anymore. In this case, the physician is left to take down new information while purging outdated information—resulting in more lost time.

In most cases, physicians and their medical staff know that the ethics behind their decision to check a box marked “complete” or to copy and paste old information are flawed. However, it all stems from physicians not having enough time to enter the data correctly. When your medical staff feels pressed for time, mistakes like these are bound to happen. Unfortunately, they can cause bigger problems in the long run.

2. Moral Distress on Medical Staff

Within your EHR, your practice can program certain “triggers” for patient symptoms. For example, if someone presents with symptoms A, B, and C, your EHR can recommend a specific course of care.

Normally, this feature is helpful—after all, you set it up for a reason! However, an instance mayarise in whiche the patient’s previous information in the EHR suggests something else is wrong, contradicting the carerecommendations inm the EHR. This could leave your medical staff in a tough spot when deciding which method of care to choose, causing moral distress.

What is moral distress?

Moral distress is caused when a member of your medical staff, specifically nurses, realizes a discrepancy in patient care, knows the right thing to do about it, but feels as if they can’t do so due to restrictions or hierarchical role conflicts.

This situation occurs frequently and may even be happening in your practice! It’s difficult for nurses or other medical staff to suggest a method of care that contradicts your physicians or EHR.

This is one of the many reasons why accurate patient data is crucial. In the above example, if the patient’s data were completely accurate, it may not cause a lapse in judgment. Instead, it would be easier for the physician and their team to unanimously decide on the correct method of care.

3. Lack of Personalization Within EHR

Another issue that causes ethical errors within your practice is the lack of personalization in EHR. While every EHR has its own settings for custom personalization, they are difficult to locate and manage. More often than not, practices end up using a “cookie-cutter” EHR that simply doesn’t work for them.

This lack of personalization affects clinical judgment because it prevents physicians and nurses from entering information as they see fit. Instead, they are left to click through multiple screens and check numerous boxes just to enter patient data. This could result in a lack of patient information or insufficient documentation.

Again, this comes down to a time issue. Your staff knows this patient’s information is necessary. However, the amount of time and detail it requires may not always seem worth it. This impact on clinical judgment is normal and can be avoided with the right solutions.

4. Physician Desensitization to EHR

When you are constantly being bombarded with notifications, pop-ups, and alerts, it’s easy to become desensitized—no matter what field you’re in!

This issue is especially prevalentin EHRsR. As if the lengthy documentation isn’t enough, physicians and nurses then have to field various pop-ups and alerts from the EHR. While these alerts may be aggravating, they are usually important and appear for a reason. However, due to desensitization, the user may be prompted to dismiss the alert.

This creates an ethical conundrum because blatantly ignoring alerts can lead to patient misinformation, which raises entirely different ethical issues.

5. Incorrect Patient Documentation

One of the biggest ethical threats to your practice is patient misinformation in EHR. While thi,s to,o stems from a lack of time,ite is more serious and canhavee legal implications.

Sometimes, members of your staff may try to work around EHR software by purposely entering false information. This lapse of judgment due to complicated EHR can cause detrimental issues for your practice and its patients.

For example, if a physician or nurse inputs incorrect patient information, that information will continue to follow the patient for the rest of their lifeOftentimes,es a patient is unaware of incorrect information, and they could be denied insurance coverage in the futurbecause ofon the false data.

More than that, the nurse or physician entering the information could be held legally responsible for the error, causing even more issues for your practice.

The legal impact of false patient information

In the healthcare industry, the need for accurate, complete, and factual information cannot be stressed enough. When a member of your medical staff submits incorrect patient information (whether accidentally, intentionally, or by “auto-fill” options) and electronically signs it, they are then responsible for that documentation.

In more serious cases, these documents can be used in court and couldadversely affectt thestaff member whot completedthems, the patien,t and your practice.

Small or large, workarounds of any kind within EHR should never be practiced. But we know that’s easier said than done. With increasing levels of physician burnout, frustration with EHRs and a lack of proper training, bypassing crucial EHR elements seems like an easy way out.

However, there is a simple way to avoid these ethical discrepancies in your practice. The answer? DataMatrix Medical.

How DataMatrix Medical Can Improve Clinical Judgment

Curious how outsourcing your medical transcriptions to DataMatrix Medical can improve clinical judgment? Here are a few main reasons:

• When you outsource your medical transcription to us, you will be gaining a team of highly skilled medical scribes (or medical transcriptionists) who will be devoted to your practice. Our medical transcriptionist training provides in-depth knowledge of medical terms, nuances, and jargon—making your transcriptions as accurate as possible. This lack of correct information will help solve ethical dilemmas such as false patient information and verification.
• Our medical scribes will listen to every word you say. This will give your documents the personalized touch they need, making it easier for your team to read and understand. Plus, we can seamlessly integrate with any EHR, allowing your practice to personalize it to meet your needs.
• We can help save your physicians’ time, too. This will allow them to focus more on patient care and less on complications within EHR. This will alleviate ethical issues caused by a lack of time, giving your practice one less thing to worry about.

We are experts in EHR, and we want to make your team experts, too. Our team can help your practice continue to growwhile steering clear of EHR issues that mcould raisea red flag.

We value clinical judgment and always take the necessary steps to follow any and all regulations to keep your practice above reproach. Want to see how we do it? Start your two-week free trial to put us to the test.

When it comes to medical transcription, words really do matter. Download our free guide below to find out why!