New research touts EHRs as aid to better diagnosis

BOSTON – A fundamental part of delivering good medical care is getting the diagnosis right. Electronic health records can help, according to new research published last week in The New England Journal of Medicine.

"EHRs promise multiple benefits, but we believe that one key selling point is their potential for preventing, minimizing, or mitigating diagnostic errors," wrote Gordon D. Schiff, MD and David W. Bates, MD of Brigham and Women's Hospital and Harvard School of Public Health in Boston.

Diagnostic errors are common, outnumbering medication and surgical errors as causes of outpatient malpractice claims and settlements, the authors note in the paper "Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?"

"The diagnostic process must be made reliable, not heroic, and electronic documentation will be key to this effort," they write. "Systems developers and clinicians will need to reconceptualize documentation workflow as part of the next generation of EHRs, and policymakers will need to lead by adopting a more rational approach than the current one, in which billing codes dictate evaluation and management and providers are forced to focus on ticking boxes rather than on thoughtfully documenting their clinical thinking."

Because information from patients' previous clinical encounters and tests will be more readily available with electronic than paper records, shifting to electronic systems could substantially improve clinicians' knowledge about the patient, they assert.

"Dr. Schiff and Dr. Bates struck a particularly relevant chord with their paper on the impact electronic clinical documentation can have on preventing diagnostic errors," said John Shagoury, executive vice president and general manager, Nuance Healthcare.

Shagoury touts speech recognition technology as one way to boost the benefits of EHRs.

"More than 150,000 physicians use our speech recognition technology to document patient encounters without having to type or handwrite," Shagoury said. The Fallon Clinic, for example,  saw the quality of medical notes improve by 26 percent when they were created using  speech recognition, according to Shagoury.

Shiff and Bates put forth several ways electronic records could help improve care:

- EHRs can serve as a place where clinicians, together with patients, document succinct evaluations, craft thoughtful differential diagnoses, and note unanswered questions.
- EHR systems should facilitate the documentation of evolving history and ongoing assessment.
- EHR systems can provide a better approach to managing problem lists if needed. The failure to effectively integrate the creation, updating, reorganization, and inactivation of items on problem lists into the clinician's workflow has been one of the great failures of clinical informatics.
- EHRs should ensure fail-safe communication and action in the areas of ordering tests and tracking the results.
- EHRs should incorporate checklist prompts to make sure that key questions are asked and relevant diagnoses considered.
- EHRs should do more to help with follow-up and the systematic oversight of feedback on diagnostic accuracy


"Clinicians need to take back ownership of the medical record as a tool for improving patient care," Shiff and Bates write. "Such a move could have many benefits, including reducing the frequency of diagnostic errors."

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