Electronic clinical documentation could help prevent diagnostic errors, according to a perspective published in the New England Journal of Medicine, Medscape reports.
The perspective -- written by Gorden Schiff and David Bates of Brigham and Women's Hospital, Harvard Medical School and the Harvard School of Public Health -- notes that "documentation practices have largely been dictated by billing and legal requirements" but that "the main role of role of documentation should be to clearly describe the patient's status and problems and to communicate these to other providers."
The authors write that while electronic prescribing has been proven to reduce errors but that other benefits of electronic health records still are unclear.
According to the authors, EHRs can help reduce diagnostic errors by:
- Sorting, organizing, and granting access to a patient's medical history and data;
- Creating a forum for discussion about evaluations and differential diagnoses;
- Allowing information to be continuously updated;
- Offering a more effective approach for managing a patient's problems list;
- Providing reliable information about order tests and results;
- Adding checklists to ensure that pertinent questions are asked and certain diagnoses are considered; and
- Facilitating follow-ups, patient education and feedback (Barclay, Medscape, 3/24).
Internet Changing Physician-Patient Relationship
In a separate perspective article published Wednesday in the New England Journal of Medicine, Pamela Hartzband and Jerome Groopman of Beth Israel Deaconess Medical Center and Harvard Medical School discuss how the Internet has changed the patient-physician relationship.
They write that the Internet's "profound effects derive from the fact that while previous technologies have been fully under doctors' control, the Internet is equally in the hands of patients," adding, "Such access is redefining the roles of physician and patient."
The authors write, "As physicians, we are struggling to figure out how best to use this technology in the interests of our patients and ourselves. Although the Internet is reshaping the content of the conversation between doctor and patient, we believe the core relationship should not change" (Hartzband/Groopman, New England Journal of Medicine, 3/25).