Understand the tricky side of templates: Research done by Sue Bowman, the senior director of coding and compliance at American Health Information Management Association, showed that if physicians generate EHR content using point and click choices, many records end up with similar or identical entries. In her paper published in Perspectives in Health information Management, Bowman also found that overuse of such prefab templates sometimes led to events being documented before they had actually transpired.
At times, wrote Bowman, templates populate certain EHR fields based on particular patient characteristics or other data entries, despite the fact that this default information does not apply to a specific patient. In one example she cited, the EHR for an amputee included the “fact” that his extremities were “normal.”
In future, technology should help
U.S. medical practices have only made widespread use of electronic medical records for about ten years. Considering the amount and the complexity of the data in EHRs, it is only natural that errors occur within the digital records and result in patient harm.
Derrow, remains optimistic that the technology will improve and make accurate, patient-specific data entry easier for doctors.
“I think eventually the problem will be solved by more intuitive software programs. That is my prayer. I suspect it will be sometime after I retire,” he says.