5 Ways EHR Impacts Clinical Judgment Within Your Practice

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

Despite the benefits and difficulties of EHR, there is a larger ethical impact it may have on your practice. When not used correctly, EHR documentation can cause lapses in clinical—and even legal—judgment within 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 your practice may be experiencing flaws in clinical judgment due to EHR. Then, continue reading to understand the positive impact a medical transcription service can have on ethical issues in your practice.

1. False EHR Data Input

Because of the lengthy documentation and time consuming administrative work, it’s easy to try to cut corners with EHR.

For example, when a physician is seeing a patient, they may forget to check a certain box or take down 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 down the road in terms of 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, however, this could cause inaccurate documentation of patient information.

The reliance on copying and pasting information can detrimentally impact patient care. This happens when old or outdated patient information is transferred into to new documents.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 In this case, the physician is left to take down new information while purging outdated information—resulting in more lost time.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 as “complete” or copy and paste old information is flawed. However, it all stems back to physicians not having enough time to input the data correctly. When your medical staff feels pressed for time, mistakes like these are bound to happen. And, unfortunately, they can cause larger issues in the long run.

2. Moral Distress on Medical Staff

Within your EHR, your practice is able to program certain “triggers” for patient symptoms. For example, if someone comes in exhibiting symptoms A, B, and C, your EHR will be able to recommend a certain path of care.

Normally this feature is helpful—after all, you set it up for a reason! However, an instance may occur where the patient’s previous information in the EHR suggests something else is wrong, contradicting the suggestions of care from the EHR. This could leave your medical staff in a tough spot when it comes to 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 due to restrictions or hierarchical role conflicts.

This situation happens frequently, and may even be occurring 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 it is crucial to have accurate patient data. In the above example, if the patient’s data was completely accurate, it may not cause a lapse in judgment. Instead, it would be easier for the physician and their team to decide unanimously on one 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” form of EHR that simply doesn’t work for their practice.

This lack of personalization impacts clinical judgment because it prevents physicians and nurses from inputting information how they see fit. Instead, they are left to click through multiple screens and check numerous boxes to simply input 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 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 prevalent when it comes to EHR. 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 are popping up for a reason. However, due to desensitization, the user may be prompted to exit out of the alert and ignore it altogether.

This causes an ethical conundrum because blatantly ignoring alerts can result in patient misinformation—which has an entirely different set of ethical issues.

5. Incorrect Patient Documentation

One of the biggest ethical threats to your practice is patient misinformation in EHR. While this too stems from a lack of time, this issue is more serious and can cause 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 life. Often times a patient is unaware of incorrect information, and they could be denied insurance coverage in the future based on 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 a court of law and could harmfully impact the member of your staff that completed the documents, the patient 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, frustrations with EHR and lack of proper training, bypassing crucial EHR elements seems like an easy way out.

However, there is a simple way to avoid all of these ethical discrepancies within 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 covers an in-depth knowledge of medical terms, nuances and jargon—making your transcriptions as accurate as possible. This lack of incorrect 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 into any EHR, allowing your practice to personalize it in a way that meets 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 that result from a lack of time, giving your practice one less thing to worry about.

We are experts when it comes to EHR, and we want to make your team experts, too. Our team can help your practice continue to grow, while steering clear of EHR issues that may cause a 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!