Electronic Health Record (EHR) Best Practices


Electronic Health Record (EHR) data entry is a part of the job, but for most physicians it’s a chore. Not only does it take time away from your patients, it adds to the hours you spend in the office (or to the work hours you spend at home). Fortunately, many physicians have found ways to save time doing data entry.

One method is with the use of a medical scribe. They are professionals that document patient information into the EHR under the supervision of the physician. Team documentation, or “scribing”, frees physicians from writing notes, entering orders or referrals, and preparing prescriptions during the patient visit. This allows for more face time with patients, increased productivity, and efficiency, and increased revenue.

There are two different types of scribes to consider for your practice: 

  • An in-office scribe follows the physician through his or her work day and charts patient encounters in real time using the EHR. The American Medical Association has a CME module, Team Documentation: Improve Efficiency, Workflow, and Patient Care, for physicians who want to learn how documentation support help can have a positive practice impact. The free module provides an eight-step, solution-oriented program, as well as case studies, information on related Medicare payment issues, and an online calculator to estimate scribe savings.
  • A virtual scribe listens to patient encounters through a secure HIPAA connection and documents as the physician interacts with each patient. After the exam, the physician reviews the patient’s chart with the scribe.


How to Find a Scribe:

Houston Community College Medical Scribe Program:

The Medical Scribe is a six-month program approved by the American College of Medical Scribe Specialists (AMCSS) that prepares the individual for the field of medical scribe. Students will learn the fundamentals of the scribe field including medical terminology, anatomy and physiology, electronic health records, medical insurance, HIPAA as well as law and ethics for the health professions.

Voice (Speech) Recognition

Another option is voice recognition software - voice (speech) recognition technology is a possible solution for practices with EHR’s as demand for comprehensive, portable records grows, reimbursements shrink and quality measurement reporting requirements expand.

Voice recognition software comes in two broad forms: front-end and back-end. Front-end voice recognition software relies on a physician or nurse to activate the software, select the right input fields while dictating notes, review the notes, and then sign off on the document. This type of software seems to be more popular because it significantly reduces the role of the transcriptionist and recoups those expenses for the hospital or practice. However, a front-end process does require a physician or healthcare provider to review and sign off on the text, which can take longer. A back-end process relies on the software to convert speech directly into text without initial oversight from the physician who dictated the notes. The text is then filtered through a template that captures the requisite clinical information. At the end of the process, a transcriptionist reviews the form, but a physician or other provider usually still signs off on the completed document.

Voice recognition can be especially helpful if you’re not a proficient typist. It also can help by making the content of your notes more complete and specific, and it helps limit cut and paste within the medical record. Most EHR vendors have voice recognition software or make it available via a third-party vendor. Check with your vendor for more information on how to get set up.

Voice recognition is not without some challenges. Training the system to learn the practice or facility language model takes some time, and in the beginning may be less efficient than traditional dictation and transcription methods because the only way for the system to learn new vocabulary is to correct mistakes in motion, as they happen. A study done by the JAMA network found an error rate of 7.4% in speech recognition-generated clinical documents. The rate fell significantly after review by a medical transcriptionist, further still after clinician review. This shows the importance of manual editing and review, user training, quality assurance, and auditing.

Below are three market leaders in voice recognition platforms:

Data Cloning (Copy and Pasting)

This practice involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in health care institutions that is not broadly addressed. The Texas Medical Board (TMB) specifically states that all non-biographical populated fields, contained in a patient's electronic medical record, must contain accurate data and information pertaining to the patient based on actual findings, assessments, evaluations, diagnostics or assessments as documented by the physician.

CMS also states that the medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter and in 2013 the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning. For additional information from CMS regarding cloning please view the EHR Provider Fact Sheet.

It is important that physicians always review copied notes to make sure they’re accurate and relevant, otherwise there could be consequences including recoupment of payments if adequate documentation for billed codes is not provided, as well as action against the physician by the TMB.

The ERCI Institute has provided a two page handout with safe practice recommendations for copy and paste to help physicians benefit from the efficiencies of copy and pasting while avoiding potential drawbacks.

Below are some additional tips to avoid the negative consequences of cloning.

EHR Contract Review

EHR contracts are important documents that define a relationship between the physician practice and vendor. These relationships can produce painful consequences for a healthcare organization if not drafted, reviewed, and implemented carefully. Contractual language is not always easy to understand and may contain unfavorable clauses, terms, and conditions. The likelihood that the contract will have some unfavorable aspects warrants a careful review to be sure you protect your interests. 

Negotiating a fair and advantageous contract sometimes requires a trained, third-party opinion to ensure you are getting the best deal possible, the Coker Group offers TMA/HCMS physician members free technology contract review services. Coker’s contract evaluation will focus on terms and conditions that may be unfavorable to TMA members. After the contract has been reviewed, you will be provided feedback on the contract, along with suggestions on how to address any identified concerns. TMA members are also eligible for five percent off of contract negotiation fees. 

To start the process, please complete the Free Vendor Contract Review - Request Form. Once submitted, a TMA consultant will contact you to walk through the next steps. Questions about this service? Email TMA, or call (800) 523-8776.

The following resources provide education and tips for reviewing and negotiating your EHR contracts:

EHR Buyer Beware: Issues to Consider When Contracting with EHR Vendors - TMA Whitepaper
EHR Contracts: Key Contract Terms for Users to Understand - Prepared by Westat for the ONC
Guide to Licensing and Service Agreements - TMA Whitepaper
Be in the Know When You Purchased an EHR - TMA Article
Before You Sign: 10 Tips for Tech Contracts - TMA Article
Four Tips for Negotiating with Your New EHR Vendor
ONC - EHR Contracts Untangled 

Reviewing and negotiating EHR vendor contracts prior to implementation is an important part of having a positive experience with your EHR. Additionally, Investing in the preparation, planning, and negotiation of an EHR acquisition can minimize business and patient safety risks.

SAFER Guides

The SAFER Guides consist of nine guides organized into three broad groups. These guides enable healthcare organizations to address EHR safety in a variety of areas. The guides identify recommended practices to optimize the safety and safe use of EHRs. PDF versions of the guides can be downloaded and completed locally for self-assessment of an organization’s degree of conformance to the Recommended Practices. The downloaded guides can be filled out, saved, and transmitted between team members.

Along with the SAFER guides the AMA, Pew Charitable Trusts and Medstar Health have released a guide with recommendations for improving the safety and usability of EHRs as well as safety test case scenarios. 

Additionally the TMA offers a two part webinar series that discusses quality and safety with EHR use. 

EHR Interoperability 

The ability to exchange and display relevant patient information is a major factor in how well an EHR system works in your practice and supports patient care. Many physicians send and receive "summary of care" documents; however, these documents are often very long and important information—like office notes and findings—is not integrated back in to the patient's record. These issues are often a result of the EHR vendor's conformance to federal technical standards.

ONC created a scorecard tool for EHR interoperability. The ONC One Click Scorecard is designed specifically to test the quality of documents used to exchange patient health information between EHRs. This tool is the health IT equivalent of an internet speed test. The scorecard can help uncover if your EHR is properly configured to send, receive and display medical documents. In addition to providing both a numerical and letter grade, the scorecard provides a user-friendly, categorized report that pinpoints areas for improvement.

Communicating the grade and areas for improvement back to your EHR vendor can help them improve your EHR's interoperability and usability.

The 2015 Edition Health IT Certification Criteria (2015 Edition) builds on past rulemakings to facilitate greater interoperability for several clinical health information purposes and enables health information exchange through new and enhanced certification criteria, standards, and implementation specifications. Physicians participating in the Medicare reporting program known as the Quality Payment Program (MIPS or APMs) will be required to upgrade their current EHR certification level to the 2015 version by 2019 to be able to participate within the EHR reporting portion of the program and receive a full score.  

ONC Health IT Complaint Form

The Office of the National Coordinator (ONC) has released a Health IT Complaint form that physicians can use to report any issues they are having with their EHR. The complaint form can be filled out and submitted online and physicians can choose to give their contact information or remain anonymous. 

Be sure to provide specific examples or solutions that the ONC will be able to verify or act upon. Although physicians can report on any issues they are having with their EHR, patient safety issues will probably be given greater priority and have greater impact. This includes any EHR designs or issues that can potentially harm patients if not corrected.

Specific examples of EHR issues related to patient safety include:

  1. An EHR system where the actual lab results and the reference range results are flipped.
  2. The Computerized Physician Order Entry (CPOE) system displays dosages and routes in a way that may cause physicians to accidentally select a different dose, route, or medication.
  3. Display charts or graphs that does not have scales or have incorrect scales causing the patient or the physician to misinterpret the graph or chart.