How Automation in Electronic Medical Records Can Lead to Errors in Dermatology

Main Article Content

Kaycee Nguyen
Clay J. Cockerell MD, MBA, JD

Keywords

requisition form, electronic health record, electronic medical record, dermatopathology, pathology

Abstract

The integration of electronic health records has revolutionized healthcare by facilitating communication among providers, but it has also introduced significant challenges. In dermatology, a particular issue arises with the use of electronic medical record (EMR) systems that employ auto-populated fields on digital pathology requisition forms (RFs) for skin biopsies. These systems allow for the rapid selection of pre-set descriptions and differential diagnoses, which, while timesaving, frequently lead to diagnostic inaccuracies and potentially detrimental impacts on patient care.


Dermatopathologists often receive biopsy specimens with RFs that list multiple provisional diagnoses based on generic, EMR-generated descriptions, which may not accurately represent the patient’s condition. This practice hampers the ability of dermatopathologists to perform effective clinicopathologic correlation, crucial for accurate diagnosis. We highlight that the convenience of EMR systems can discourage clinicians from recording detailed, accurate clinical observations. Consequently, this lack of detailed documentation prevents dermatopathologists from making informed diagnoses by correlating histologic features with clinical appearances. The current practice of using EMRs without consideration for their clinical relevance not only wastes healthcare resources but also poses a significant medico-legal risk. Therefore, refining EMR practices and integrating more comprehensive clinical data will ensure greater accuracy in dermatological diagnoses. 

References

1. Muhiyaddin R, Elfadl A, Mohamed E, et al. Electronic Health Records and Physician Burnout: A Scoping Review. Stud Health Technol Inform. Jan 14 2022;289:481-484. doi:10.3233/shti210962

2. Budd J. Burnout Related to Electronic Health Record Use in Primary Care. J Prim Care Community Health. Jan-Dec 2023;14:21501319231166921. doi:10.1177/21501319231166921

3. Waller JM, Zedek DC. How informative are dermatopathology requisition forms completed by dermatologists? A review of the clinical information provided for 100 consecutive melanocytic lesions. J Am Acad Dermatol. Feb 2010;62(2):257-61. doi:10.1016/j.jaad.2009.06.049

4. Romano RC, Novotny PJ, Sloan JA, Comfere NI. Measures of Completeness and Accuracy of Clinical Information in Skin Biopsy Requisition Forms: An Analysis of 249 Cases. Am J Clin Pathol. Dec 2016;146(6):727-735. doi:10.1093/ajcp/aqw186

5. Comfere NI, Sokumbi O, Montori VM, et al. Provider-to-provider communication in dermatology and implications of missing clinical information in skin biopsy requisition forms: a systematic review. Int J Dermatol. May 2014;53(5):549-57. doi:10.1111/ijd.12330

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