Part I
There are numerous records that we maintain, or are maintained on us, over the course of our lives. Our school records track our grades and accolades. Our public records track our civic life and criminality. Our resumes document our accomplishments and abilities. And our medical records compile the history of our overall health and wellness throughout the course of our lives. Inevitably, we are all dependent on the precision of these records to portray ourselves truthfully. Any inaccuracy could have a monumental impact on some aspect of our lives. Missing credits could keep us from graduating. A mistake in our criminal background could result in the loss of liberties. And an error in our medical records could cost us our health, perhaps even our lives.
Patient Perception on Healthcare Safety
We trust doctors, as we should. They’re dedicated, intelligent, and went to school a lot longer than most of us did, so we put our health and well-being in their hands and trust that they will know how to fix us and keep us healthy. A recent study out of the University of Chicago and the Institute for Healthcare Improvement found that 90% of Americans interacted with some kind of healthcare provider in the last year, and that most people’s experiences were positive. The care was comprehensive, the physicians were attentive, and they understood how to care for themselves after their visits. (1) Over all, Americans do not feel that they run the risk of experiencing a medical error. However, this could largely be contributed to a general misunderstanding of what, exactly, constitutes one.
Defining “Medical Error” and Patient Experience
For most of us, the thought of “medical error” conjures images of a scalpel left inside of us after a surgery or something else gruesome, newsworthy, and incredibly unlikely to ever occur. In reality, a medical error can mean a simple miswording in diagnoses, perhaps stating an injury to a right foot instead of left, or a few switched numbers in a medical code show you diagnosed and treated with something else entirely. The same study found that, after having the term “medical error” defined to them, 21% of participants expressed that they had personally experienced a medical error, while 31% said that they had cared for someone who had experienced one. All total, 41% of adults in the United States have either personally experienced a medical error in their own care, or were directly involved in caring for someone who had. (1)
The Consequences of Medical Errors
When it comes to medical errors, 41% is a disparaging, and frankly, frightening number, especially considering that 73% of people who reported experiencing a medical error or caring for someone who had said that the mistake had some kind of long term or permanent health detriment or financial impact. There is also a clear correlation between medial errors and harm with 36% of patients who reported personally experiencing a medical error also reporting that they had been harmed while receiving medical care. (1)
Another alarming statistic coming out of this study is that only about 1/3 of the participants who reported experiencing a medical error were made aware of the error by someone at the facility where they were treated. Around half of the participants brought their medical error to the attention of medical personnel on their own. (1) The important assumption to then take from this data, is that not only are medical errors occurring frequently, most of them are not being caught by medical personnel or facility staff. This leads then to the even larger issue of medical disparity, as medical record errors tend to impact vulnerable populations more so than populations with greater health literacy, a factor closely tied to education and income.(1)
Of the participants who reported dealing with medical errors, 59% reported that the error was centered around diagnosis, where the patient was either diagnosed incorrectly, had a delayed diagnosis, or was not diagnosed at all when they were, in fact, ill or injured. (1) The reasons for misdiagnosis are broad and varying, and misdiagnosis is the leading cause of medical malpractice suits in the United States. Diagnostic errors can have dire, long lasting, and even fatal consequences for patients, and yet they are so common that nearly everyone will experience at least one incorrect or delayed diagnosis in their lifetime. (2)
The question then becomes, what is causing such a high prevalence of medical errors and what can be done to rectify that?
Changes in Medical Documentation and Resulting Challenges
In 2004, thanks to new government incentives, medical records began to change with a push from paper charts to electronic archives. While the benefits of EMRs are undeniable—they can lower costs, enhance efficiency, and make patient records immediately available across care settings– the transition, unfortunately, has been less than smooth. Many medical facilities are still scrambling to fully and comprehensively changeover. (3)
One of the biggest hinderances to care and sources of medical errors is the extra documentation burden that now falls on doctors. Prior to EMR, physicians would fill out charts or record their observations, and those documents would then go to a trained medical transcriptionist, a coding expert, and then a billing specialist. In this new system of clinical documentation, doctors are responsible for filling out patient charts and coding, often using clunky systems that they are ill-trained to use. (3) Not only does this result in a substantial amount of physicians’ time shifting from patient interaction to documentation as they navigate unfamiliar and complicated computer programs, but it also drastically reduces the potential for any mistakes that physicians might have made to be caught and queried by professionals trained in transcription and coding.
In addition to the obvious consequences placed on patients when medical errors arise from EMR complications, medical documentation is also a significant factor in the increasing rise of physician burnout. Physicians report higher levels of job dissatisfaction when the amount of time they spend on documentation encroaches on, and even surpasses in many cases, the amount of time they spend on patient care. (4) Essentially, new clinical documentation standards are forcing doctors to perform tasks and use technology with which they’ve had practically no training, resulting in transitional delays with the learning curve, professional frustrations, and a high prevalence of mistakes.
New Solutions in Traditional Practices
Medical errors are costly and dangerous and combatting them is a top priority in patient safety and hospital efficiency. With EMR hiccups contributing to a substantial amount of errors in medical documentation, the most obvious solution to begin combating medical error is to elevate the quality, capabilities, and usability of clinical documentation workflows. New software solutions and technology, specifically backend speech recognition and natural language processing, are capable of significantly improving the quality and accuracy of medical transcriptions.
The traditional transcription model where physicians dictate patient encounters and trained transcriptionists and coders review the reports to ensure quality and integrity is by far the most comprehensive way to prevent medical errors. Thanks to advancements in transcription technologies, the cost of transcription has come down significantly, and can more than offset the costs accumulated as a result of the medical errors it can eliminate. With new solutions and technologies, the outlook for not only reducing medical error, but enhancing the entire system of medical transcription and diagnosis, is exciting and promising.
