Don’t Let an EHR Template Determine Your Standard of Care

  • January 21, 2015
  • Ann Whitehead, RN, JD

If you are contemplating the purchase of an Electronic Health Record (EHR) system, it is important that you and/or your physicians take time to review each system’s medical record templates. Many systems have predetermined templates that allow minimal customization. Other systems offer greater customization options for a higher price.

The important thing to keep in mind is that an EHR template is nothing more than a boilerplate, written by a third party or “expert” to input clinical data. The inflexibility of this template presents a series of fundamental problems that will crop up during everyday use, specifically:

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  1. The template is someone else’s thought process and incorporates assumptions about what you think and how you should practice medicine.
  2. The template is generated to cover a wide variety of practices and encounters, making it very general.
  3. Templates tend to take a cookie cutter or one size fits all approach, with no regard for age appropriateness or target patient population.
  4. Some templates allow very little room for free text, thus limiting the information, which can be entered.

One of the biggest dangers presented by templates is that they may set the standard of care to which the physician may be held. Acceptance of an EHR template may be viewed as your standard of care. Therefore, when choosing an EHR system, physicians should consider the following:

  1. Does the system allow you to use your own forms?
  2. Can you mirror the way you practice today and improve it?
  3. What is the cost for customization of templates?
  4. Does the system have an e­prescribing function?
  5. Does it provide for secure messaging?
  6. What will the vendor charge for modifying a template?

The bottom line? You should select an EHR system that best fits the needs of your practice or medical group, and that closely mirrors your practice’s current templates.

 

Author Ann Whitehead is Vice President of Risk Management & Patient Safety for the Cooperative of American Physicians, Inc (CAP).

 

If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.