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Technical Review of Your EHR Options


An article by Ron Sterling, taken from the May/June issue of HBMA Billing (

In addition to the functional capabilities of any EHR options that you may be considering for your billing service, you need to verify the technical design of the EHR to ensure that not only will your clients be able to manage workflow and chart patient notes, but that their information will also be protected and managed within the EHR.

Technical issues will become more significant due to the problems and exposures that have surfaced with a wide range of EHR products. For example, some EHR users have discovered missing documents and images when their EHR informs them that "the file could not be found." As importantly, Stage 2 of the Meaningful Use standard includes several measures that will require more tools and additional connections between information stored within an EHR. Among other considerations:

Stage 2 includes the management of images in an EHR. Many EHR products lack a full panel of tools to manage images. For example, a diagnostic test image may be stored in the EHR, but the image may lack connections to the appropriate date of service or even the clinical event that triggered the test.

Stage 2 extends computerized order entry to lab and radiology orders. The exchange of information with pharmacies, labs, and radiology providers will require more electronic services as well as referential integrity within the EHR. For example, many EHRs have programmed management tools for electronic prescriptions, but deal with other orders in a less structured manner. Indeed, many EHR products use messages to inform staff of the need for a diagnostic test but do not programmatically track the status and fulfillment of the order.

Issues to consider include:

Does the EHR maintain the integrity of patient medical records over time? Maintenance of the information entered and documents created by the practice substantiate the care provided to patients and fulfill a wide array of legal and professional requirements. However, in too many cases, EHRs do not adequately protect the historical documents and information.

For example, many EHR products support amendments to EHR records through the insertion of free text notes in record files. However, free form notes do not affect the structured information in patient charts ( e.g., specific patient findings). Thereby, EHR features, including health maintenance items, may not be properly triggered if a free form text amendment contains related information.

A number of EHR products make extensive use of Word to generate patient documents, letters, and forms. However, in many cases, the Word file is maintained as the audit trail of the letter, but that audit trail is not protected from further updates or manipulation. In some cases, the EHR generates the document each time the user views the item, but does not save a copy of the document that was sent to the patient or referring doctor.

Does the EHR retain important information about patient encounters and related messages? A wide array of information is collected in an EHR system in the course of a patient visit or in support of a patient phone inquiry. However, many EHR products depend on procedures and user actions to make sure the appropriate information is entered into a patient's chart.

For example, some EHRs do not include messages as part of the patient record. Interactions between staff on a patient issue or problem that is recorded in a message will not be in the patient chart and may be purged from the EHR on a periodic basis. Consequently, the user has to make a decision about entering the information on an exam note or a message before dealing with the patient issue.

Does the EHR facilitate maintenance of timely patient records? Timely entry of information and management of patient service items are basic responsibilities for a medical practice. However, some EHRs do not practically support the responsibility for fully managing patient charts on a timely basis. For example:

A number of EHR products do not track the status of patient information that is in the EHR. In a paper chart, you can tell if the doctor has reviewed the document by their signature. However, in an EHR, you may have to check several places to uncover whether a specific document or item has been reviewed.

Many EHRs allow users to manipulate the date of a document, subsequently affecting the presentation of information in a chart. This could lead to a circumstance where, for example, a diagnostic image is not properly paired with the appropriate exam note.

Few practices are equipped to technically review the integrity and design of an EHR for reliability and long-term storage of critical patient records. In your search for EHR solutions for your clients, insuring that the EHR maintains the integrity of the patient record is as important as the charting capabilities and user interface. Otherwise, the information that the provider is expecting to access may be missing or distorted.

Ron Sterling (800-967-3028, publishes the popular EHR blog,, and authored the HIMSS Book of the Year Award winning Keys to EMR/EHR Success. Ron is a frequent presenter on EHR issues for HBMA. © Sterling Solutions, 2012
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