• Electronic Health Record (EHR) Best Practices



    Many physicians say electronic health records (EHRs) have not made their lives any easier. Though the systems have the potential to improve accuracy and efficiency in a medical practice, EHRs often mean extra administrative work for physicians and less face time with patients. A scribe may help alleviate some of these issues, however, each physician and/or physician practice should evaluate their Return on Investment (ROI) carefully before hiring a 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 & physiology, electronic health records, medical insurance, HIPAA as well as law & ethics for the health professions.


    Voice (Speech) Recognition

    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 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.


    Additionally 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 & 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 & paste to help physicians benefit from the efficiencies of copy & pasting while avoiding potential drawbacks.

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





    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.




    Below are short tips from physician practices on how they were able to improve the use of their EHR systems.


    • Ask vendors to provide web based training with desktop sharing capabilities.  This will allow each staff member to train at their own work station with a familiar computer. This will also allow for training flexibility and limited disruption of the clinic's operations.
    • Staff training should be focused on EHR functions applicable to the staff's job function.
    • Designate a staff champion that will stay up-to-date with the system; budget for him/her to attend the yearly user conferences provided by the vendor.
    • A good consultant with IT experience as well as healthcare experience can provide advice, templates, and strategies.
    • Explore the use of tablets or other hand held devices instead of a lap top.
    • Consider having remote access to your EHR for additional flexibility.
    • If transitioning from paper charts: 
      • Stage the data migration.
      • Be selective about what staff should re-entered and what should be scanned.
      • Be consistent about what scanned files are named and in which folder or category these files are kept within the EHR system.  
      • For example, scan the paper charts of established patients a week prior to a patient visit.  
    • Physician and staff should test the system and create the basic template and modifications prior to the live implementation date.  


    Case studies:



    • Process or clinic work flow changes
      • Ask patients to bring their prescription bottles to their appointment.  Enter the information in to the EHR system along with the patient's smoking status and relevant medical, surgical, and family histories.  This will help initiate the electronic prescribing process.
      • Consider allowing nursing staff to begin checking patients out and printing visit summaries. This change will allow the patient to ask questions to a clinical staff member before they leave. 
      • Have patients fill out a new medical history sheet. Key in the up-to-date data from the new sheet, rather than trying to key in old data.
      • Kiosks can enable patients to quickly and immediately check-in upon arrival and update any needed health information without waiting for direction from the staff.
      • Make use of the new space that is available after the paper charts are transported to an off-site location. Consider turning the space into additional exam rooms, which may result in improved access to patients and increased provider revenue.   
    • EHR organization, modification, customization
      • Attach laboratory and radiology reports to the corresponding order in the EHR so the records can be more easily located in the future.
      • Link best practice alerts to orders. This will allow clinic staff and providers to easily click on the order and prescribe the appropriate tests and/or treatments. 
      • Invest in and implement automated components for tasks like checking patient eligibility and generating patient statements to help safe time.
      • Incorporate a claims rules engine into the EHR to prevent the most prevalent causes for claim denials. Rules and warnings can be incorporated into this engine that will help staff review and correct unclean claims before they are submitted. By implementing this system, additional revenues can be gained and coding burdens will be shifted away from the providers.
      • If the EHR allows the staff to create templates, everyone should resist the temptation to immediately start creating their own templates.  Custom templates may prevent certain required fields from populating or may prevent the flow of information in the system. First, become accustomed to using the EHR to document how the clinic actually provides patient care. Then, develop  templates based on that reality. This will save time and money.
      • When something isn’t working correctly in your EHR, try to fix it on the spot. If that is not possible, make a note of it and return to fix the problem as soon as you can. Tolerating inefficiency or system dysfunction fosters development of bad habits. If allowed, these bad habits will become the new standard, decreasing your efficiency of EHR use and delaying returns on investment.

    Case studies:



    • Process or clinic work flow changes
      • Phase in EHR adoption if the practice has more than one clinic location. 
      • Be sure patients are informed of any changes or modifications to their patient portal prior to a system upgrade.
      • Consider having staff sign up as patients to test and give feedback on the parts of the EHR system with which patients will interact.  
    • EHR organization, modification, customization
      • Be selective in the functionalities and customizations. 
      • Ensure a good backup database
      • No EHR will be a perfect fit.  Therefore, look for and know the weakness of EHR systems before buying 
      • Consider providing multiple platforms for providers to enter information including, computers, laptops, tablets.

    Case studies:



    • Process or clinic work flow changes
      • Phase in EHR adoption if the practice has multiple locations.
      • Use nurse care managers and a team-based approach toward care to emphasize coordination of care across every setting.
      • Consider building a clinical quality department to support offices with EMR usage. This department should also continuously look at data to determine how to improve quality.
      • Make patients a part of the process. Ensure that your patients know about the EMR transition, what glitches in the system might occur, and how the new process will benefit them.
    • EHR organization, modification, customization
      • Use an incorporated EHR/PM system to increase coding efficiency.
    • Technology issues
      • Wireless access points should be place to ensure robust coverage without areas of signal dropout.
      • Computers should not be operated in an administrative mode.  This mode makes computers much more susceptible to viruses and unintentional downloads.

    Case studies: