ED patient encounters not accurately documented in EHR

Documentation in electronic health records did not match observed and recorded physicians' behaviors during patient encounters, according to a study of emergency department residents.

The study, published on Wednesday in the journal JAMA Network Open, involved emergency departments in two academic medical centers where residents’ patient encounters were observed to compare real-time performance with EHR documentation.

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“No other study has attempted to quantify the accuracy of electronic physician documentation using concurrent observation,” the authors contend.

In the study, nine residents were shadowed by trained observers for 20 encounters—10 encounters per physician per site—to gather real-time observational data, with the associated EHR data subsequently reviewed.

According to the authors, there were “inconsistencies” between the documentation of review of systems (ROS) and physical examination (PE) findings in the EHR and observational reports.

“While physicians may commonly dictate or type a customized history of present illness or medical decision-making note,” the study makes the case that the ROS and PE sections of the EHR may be prone to inaccuracy because of the use of autopopulated text.

“These findings raise the possibility that some documentation may not accurately represent physician actions,” conclude the study’s authors, who note that despite the widespread adoption of EHRs little investigation has been conducted into the accuracy of physician documentation. “Further studies should be undertaken to determine whether this occurrence is widespread.”

At the same time, researchers contend that “because such studies are unlikely to be performed owing to institution-level barriers that exist nationwide, payers should consider removing financial incentives to generate lengthy documentation” for ROS and PE.

The authors are encouraged by the fact that the Centers for Medicare and Medicaid Services appears to be “moving forward incrementally” to remove such incentives as evidenced by “recent announcements regarding physician payment documentation requirements for outpatient office visits that will take effect in 2021.”

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