4 ways EHR improves medical data entry

We often hear that EHR will make healthcare more efficient, accurate, and quick. But, what do speed, accuracy, and efficiency look like in this context? Many benefits can be observed in the back-end processes of your practice. Specifically, information is collected and data is sent to data entry employees. Here are four ways EHR improves medical data entry processes.

1. Data population

With EHR comes templates. Some templates include structured data, which means information from the EHR can populate forms within the EHR. The best example is a HCFA. A physician sees a patient, and inputs information about the diagnosis, procedures done, etc. After these EHR data sets are entered, coders review the information for appropriate billing CPTs and diagnosis codes. Finally, using a HCFA structured data template, a claim can be filled out automatically and billed immediately.

2. Limited duplicate entries

EHR allows processes to be automated. For data entry, automation reduces the number of duplicate EHR data entries, and therefore fewer mistakes are made. A good example follows the HCFA example from before. Although a second claim could be correct, if someone mistakenly tries to create a second medical claim for the same date of service, the system can flag the claim for review, particularly if the claims share the exact same information (CPTs, diagnosis codes, providers, etc.).

Recommended reading: EHR implementation: 6 steps to success

Flagging a claim for review ensures an erroneous duplicate claim will fail to go to the insurer, resulting in fewer denied claims. Similarly, the system catches duplicate patient records, so that anyone trying to input an individual as a “new” patient will receive a message if the patient already has a record within the EHR.

3. Less time between collection and entry

One of the most inefficient parts of EHR data entry used to be the time taken from data collection to data entry. Registration information, encounter details, and more might sit in a stack of papers for days before being given to the appropriate medical data entry worker. Not only does this result in possible mistakes (particularly if the worker could not go back to the original physician or employee to verify information), but it results in claims going out later, possibly outside timely filing if there is an extended data entry delay. EHR offers physicians and office staff a chance to enter all pertinent information during a visit, which in turn reduces medical data entry after the fact.

4. Voice-to-text medical records

Finally, the transcription of dictated notes leads to a delay in updating medical records. If a physician has a tight schedule and little time to write office notes, an insurance carrier requesting additional information might deny a claim due to the untimely receipt of those records. In particular, providers of surgical services sometimes have limited time to sit down and record their surgical notes comprehensibly. On top of that, transcriptionists still need to listen to the recordings and type notes.

Most EHR have voice-to-text features for physicians who have dictated notes. They speak the procedure and impression details while in their office, which is recorded and translated into text. From there, it is easily uploaded and saved to the patient’s record within the EHR, allowing anyone who needs the EHR data to find it. This limits the number of errors in a medical data entry since it comes directly from the physician’s lips, so to speak.

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Samantha Williams

About the author…

Samantha Williams’ EHR expertise stems from three years of medical billing for a large physician practice in New York City. She trains new hires to use a medical billing and EHR system and writes appeals for denied neurosurgical procedures, resulting in additional insurance payment.

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Samantha Williams