In contemporary healthcare, rectifying EHR errors is fundamental for patient safety. Research reveals a notable prevalence of errors, prompting the need for a comprehensive approach to address discrepancies. Patients, equipped with access to their medical records, play a crucial role in detecting and flagging inaccuracies. While healthcare providers shoulder the responsibility for EHR maintenance, involving patients in error identification signifies a paradigm shift toward collaborative patient care. The process involves patient-initiated requests for corrections, mandated by HIPAA regulations, wherein patients engage with providers to rectify errors. By embracing patient involvement, healthcare organizations can fortify patient safety initiatives, fostering a partnership between patients and providers for accurate and reliable medical records.
Enhancing patient safety in healthcare demands a robust system to address Electronic Health Record (EHR) inaccuracies. The convergence of patient data accessibility and engagement necessitates a collaborative approach between healthcare providers and patients in identifying and rectifying errors within medical records. While clinicians traditionally lead EHR corrections, the increasing involvement of patients presents an opportunity to improve accuracy and mitigate risks. Understanding the prevalence and impact of EHR errors, alongside patient roles in error detection, serves as a pivotal foundation to optimize correction processes. Patient data access empowers individuals to scrutinize records, flag inaccuracies, and catalyze improvements in overall patient safety.
As the pursuit of enhanced patient safety persists, healthcare organizations must establish robust processes to meet patient demands for EHR and medical record rectifications.
EHR and medical record corrections involve updating previously erroneous medical information stored in electronic records. While healthcare providers traditionally spearhead these corrections, the evolving landscape of patient data accessibility and engagement means patients increasingly detect inaccuracies and request amendments.
Recognizing the broad spectrum of medical record errors and the role patients play in identifying them allows organizations to refine their approaches to reviewing and rectifying these errors.
HOW FREQUENT ARE EHR ERRORS?
EHR inaccuracies are not uncommon. Research in 2020 revealed that one in five patients identified errors in their medical records. Design flaws in EHR systems might contribute to these issues, with separate data indicating that EHRs overlook approximately one-third of the errors they’re intended to detect.
Compounding this, clinicians often resort to workarounds to navigate usability issues in EHR systems, perpetuating errors. A study in 2022 by JAMA Network Open revealed that nearly half of EHR notes include redundant information, leading to the documentation of incorrect data over time.
The prevalent types of EHR errors encompass:
– Prescription errors, spanning incorrect dosages to flawed allergy information.
– Misleading treatment outcomes.
– Absent lab and pathology results.
– Erroneous or absent medical history and symptom details.
– Inaccurate diagnoses.
– Absent information from other providers.
– Flawed patient demographics and social determinants of health.
– Inaccurate copy-paste actions.
These errors significantly impact patient safety. Clinicians rely on EHRs to comprehend patient health and make critical medical decisions. When these records harbor inaccuracies, healthcare providers might make decisions adversely affecting patient well-being. For instance, a patient could receive a prescription for a medication they’re allergic to if the EHR’s allergy list is incorrect.
While clinicians and healthcare organizations bear responsibility for maintaining accurate records, the industry increasingly emphasizes involving patients. This approach mitigates clinician burnout and navigates the limited interoperability of EHRs between providers. Patients, being experts in their medical histories, are recognized as pivotal partners in enhancing patient safety by some healthcare professionals.
Patient access to data empowers individuals to review their records, identify inaccuracies, and request corrections. Subsequently, providers scrutinize and rectify these issues, leading to an overall enhancement in patient safety.
PATIENT DATA ACCESS AND IDENTIFYING EHR ERRORS
For patients to flag EHR errors, they must have access to their medical records, mandated by regulations such as HIPAA and the 21st Century Cures Act. Healthcare entities must provide patients access to their electronic medical records and clinician notes.
In the 2020 study, where a fifth of patients identified EHR errors, 40 percent considered these errors serious. Patients were most concerned about inaccuracies related to diagnoses, followed by medical history, medication or allergy errors, and issues concerning tests, procedures, or results.
Another study by patient advocacy group OpenNotes, advocating for open patient access to clinical notes, showcased the success of this approach. Among the 29 percent of patients who reported a medical error via patient data access, 85 percent expressed satisfaction with the resolution. While specifics of the resolutions weren’t detailed, they could range from providers clarifying certain documentation to EHR corrections.
Healthcare organizations can’t merely rely on a passive patient data access approach for EHR correction requests. Some patients are more inclined to identify EHR errors than others. The 2020 study highlighted that female patients, those with higher education, individuals with more severe health conditions, those aged 45 or older, or those already accessing multiple clinical notes were more likely to flag errors.
Another study revealed that racial and ethnic minorities were less prone to reporting EHR errors. Barriers included a reluctance to be seen as troublemakers or difficulties in understanding how to report documentation errors in the EHR.
Incorporating patients into broader patient safety efforts specifically EHR error reporting necessitates robust engagement strategies. Providers should educate patients about their rights to access their medical data and review their records for discrepancies. Healthcare organizations must also delineate proper channels for patients to report EHR documentation errors.
PROCESS FOR ADDRESSING EHR DATA ERRORS
HIPAA not only mandates patient data access but also protects patients’ rights to request EHR corrections. Covered entities have 60 days under HIPAA to amend or notify the patient if they reject the correction request.
Patients seeking EHR documentation corrections typically begin by contacting their provider’s office. Offices often provide a form for completion or require patients to draft a letter detailing the correction.
The letter should include patient information, provider details, service dates, a concise explanation of the necessary correction and its justification, and where the mistake was discovered.
Patients should retain a copy of their request and, if applicable, identify individuals legally responsible for the patient (e.g., for pediatric patients). These legal guardians may request corrections on behalf of the patient.
OpenNotes highlights that healthcare providers aren’t obligated to make EHR documentation corrections if they believe there’s no error. However, changing a record, even for clarification, isn’t straightforward and relies on individual practice environments. Providers might document changes as addenda or utilize institutional mechanisms for editing/correcting notes.
Should providers opt to correct an EHR documentation error, merely deleting the original text isn’t advised. Experts suggest flagging the EHR to indicate an update or correction, with the original document remaining accessible. Adding a comment field typically suffices for EHR corrections, as advised by experts affiliated with the State University System of Florida.
EHR vendors also play a role; providers must use an EHR system to enable corrections. The technology should track document changes, and timestamp corrections, and direct users to the original data when viewing the corrected information.
Upon correction or clarification—or in cases where no action is taken—healthcare organizations are better poised to bolster patient safety. Patient requests for medical record corrections contribute significantly to strengthening patient engagement and promoting active patient involvement in care.
The collaborative involvement of patients in EHR correction processes heralds a transformative era in healthcare. By granting patients access to their medical records and facilitating correction requests, healthcare organizations pivot towards patient-centric care models. Encouraging patient engagement in detecting and rectifying EHR errors not only enhances accuracy but also signifies a paradigm shift towards patient empowerment and partnership in healthcare decision-making. Educating patients about their rights, simplifying the correction process, and fostering strong patient-provider communication channels are vital. Ultimately, leveraging patient contributions in EHR corrections bolsters patient safety initiatives, ensuring accurate medical records and paving the way for a more transparent and patient-centric healthcare landscape.
