This is a guest article by Isaac Smith, healthcare administration professional
Electronic Health Records (EHR) have revolutionized healthcare practices, offering numerous benefits in various aspects of patient care. One area where EHR has made a significant impact is medication management and error reduction. This article explores the role of EHR in transforming medication management processes, the impact on reducing medication errors, enhanced medication management practices, case studies and research findings, challenges and considerations, future directions, and concludes with a summary of the overall impact of EHR.
The Current State of Medication Management
The healthcare industry recognizes that medication errors are among the most common preventable causes of injury, disability, and death. This includes both dispensing and administration errors, as well as the prescribing and transcribing of drugs. Indirectly, medical errors also add to the nation’s already high healthcare costs through lost productivity and extra expenses related to treating drug-related injuries.
Fortunately, there are a number of potential interventions to reduce and eliminate medication errors. These include EHR patient portals with a variety of functionalities that promote and monitor safe outpatient medication use.
Another way to improve medication management is to enhance communication between patients and their health professionals. This is done by providing patients with a means to track their medication list and share it with their caregivers. In a quantitative study of users of an online PHR, the patients were more interested in accessing their current medication lists than they were in seeing the results of their laboratory work.
Introduction to Electronic Health Records (EHR)
Designed to replace paper charts, EHRs allow clinicians to view patient histories, create new prescriptions and refill old ones, order lab or radiologic tests, and receive results electronically. They can also communicate with patients through secure messaging and access billing information for insurance claims.
While the use of EHRs can improve physician productivity and increase patient satisfaction, they also introduce new sources of error. These include problems with information display, difficult data entry, and failure to alert users of potential risks.
Another issue is a lack of training and support for the technology. For example, an EHR may require that specific fields be filled out before a record is created or orders can be processed. In one case, the requirement that an Apgar score be entered delayed treatment for a newborn baby girl who was in distress.
Providing patient access to their own health records can decrease medication errors, but only if the information is organized and easy to understand. Qualitative research on consumer-controlled EHRs found that most people liked seeing a listing of their current medications.
Role of EHR in Medication Management
While EHR can help reduce medical errors by allowing physicians to double-check and validate information before sending it, they cannot prevent all of them. Some errors may still be caused by user error, especially if staff members are not familiar with the EHR’s data input interface or are not trained to use it.
However, when used correctly, an EHR can improve workflows and decision-making. The EHR’s data and metrics serve as a tool to identify trends in patient healthcare quality and emerging areas of risk within the organization.
In addition, the EHR can aid in improving medication management by flagging medications that a patient is allergic to or could have dangerous interactions with other drugs. It can also alert clinicians to laboratory values that require immediate attention. Unintentional mistakes are reduced as well when an EHR alerts clinicians to problems they might not have noticed by reviewing a paper chart or communicating with colleagues. Moreover, it allows a unique view of the patient’s health history that travels with them throughout the healthcare system.
Impact of EHR on Medication Error Reduction
Aside from reducing paperwork and speeding up the process of documenting patient data, EHRs help reduce medical errors by alerting clinicians to medication or laboratory values that are in conflict or dangerous ranges. This information can also clue the clinician into possible interactions that they were unaware of and would not have detected if they were simply using a paper chart.
The EHR system can provide helpful features for minimizing medication error, such as alerting the clinician to potential drug-drug interactions or contraindications and offering preadmission screening tools that identify patients who are at high risk of rejection following kidney, liver, heart, or organ transplantation. Additionally, many EHRs contain features that allow the clinician to set recurring doses and reminders for specific times or intervals, which can help prevent errors that may occur if a default setting supersedes the user’s instructions.
However, some EHR systems may require the clinician to complete certain functions before the record can be created or orders processed. For example, one hospital required that staff first enter a child’s weight and Apgar score before establishing a pediatric emergency record, which caused delays in the treatment of an infant who was suffering from a life-threatening condition.
Enhanced Medication Management Processes with EHR
EHRs provide clinicians with access to a patient’s complete health care record, including past medical histories, current medications and important demographic data. This comprehensive information can help physicians make decisions that improve patient outcomes and ensure that the patient receives the highest quality of care.
Many practices implement their EHRs using a “big bang” approach, moving all of the physicians and patients over to a new electronic system on a single day. This can be disruptive, and small glitches can become amplified. Practices can minimize the disruption and risk of medication errors by slowly introducing the new system. For example, they can start with e-prescribing and move on to other functions, such as visit note documentation in a phased approach.
Some EHRs allow physicians to use a feature that checks a patient’s medications against a list of drug side effects and contraindications. These features can help to prevent medication errors caused by incorrect or incomplete medication lists and ensure that the right medication is prescribed to the right patient. Patients themselves can also benefit from this feature by receiving lists of their own prescriptions and a summary of why each is being taken.
Paperwork and Information Handling with EHRs
In addition to helping clinicians understand trends in their own practice and areas of potential risk, the EHR helps reduce paperwork and saves time by allowing clinicians to view patient records instantly anywhere they are in a hospital. This allows them to avoid wasting valuable time waiting for paperwork from other clinics and hospitals, deciphering illegible handwriting, or trying to interpret old, out-of-date information in paper charts.
The EHR also contains information about a patient’s past medical history and any future plans for treatment, so that all clinicians have access to the same record. This information is stored securely over the Internet in a digital format that can be shared across different facilities and even health care systems.
One of the most important benefits of an EHR is that it allows clinicians to instantly access a patient's complete medical history and other relevant data. This includes current medications and past prescriptions, demographic information that can affect medication management, as well as reports from any clinician who has cared for the patient.
This enables physician medical billing and coding to quickly and efficiently identify operational problems that can lead to errors. In a paper-based setting, these errors would not always be easily identified and could go undetected for long periods of time.
Addressing Challenges and Considerations
Although the benefits of EHRs in reducing medication management errors are significant, the technology is not without its shortcomings. It is important to understand the reasons behind EHR challenges and address them to ensure safe, effective use.
Many of these problems are related to poor design and usability of the system. For example, some systems require clinicians to select a medication name from a list or database, and if the drug has recently been introduced, it may not be listed. This can result in a prescribing error when clinicians click on incorrectly spelled or sound-alike medication names.
Additionally, it is vital to ensure the quality of data and accuracy of information in the EHR. This requires implementing robust, scalable processes for documenting patient-related information. Some solutions include identifying tech-savvy staff to help train other employees and improve documentation practices.
Another challenge is ensuring that EHRs can interoperate between facilities and between organizations, especially when using different software. This can be challenging for small and medium-sized clinics that do not have the resources to create or maintain an in-house technical team.
Nonetheless, some features of an EHR can create new safety risks. For example, a hospital's EHR system may require staff to input certain data in specific fields for the record to be created or the order to be processed. This can delay treatment, such as when a newborn's weight and Apgar score are not entered before the clinician can prescribe an antibiotic or acetaminophen. This is a risk that can be addressed by ensuring that the system's default settings do not override the physician's decision-making process.
Conclusion
The integration of EHR with medical billing services allows for efficient documentation of patient encounters. Physicians can document the necessary clinical information directly within the EHR system, ensuring accurate and complete coding for billing purposes. This streamlines the workflow, reduces the risk of missing or incomplete documentation, and supports appropriate coding and billing for the services provided.
Isaac Smith is a highly accomplished healthcare professional with over 13 years of experience in healthcare administration, medical billing and coding, and compliance. He holds several AAPC specialty certifications and has a bachelor’s degree in Health Administration. He worked previously at a large multi-physician family care and occupational health practice with two locations in northwestern PA and now works for Medcare MSO in the medical billing department to write articles about medical coding. He enjoys sharing his knowledge and experience as a certified PMCC instructor. He has authored many articles for healthcare publications and has been a featured speaker at workshops and coding conferences across the country.