HIT Debates Data Entry Responsibilities

Members of the HIT policy committee squabbled over a measure in the Stage 2 meaningful use requirements that would allow licensed professionals or scribes to enter data into electronic health records on behalf of doctors, according to an article in a recent issue of Healthcare IT News.

Nurses often enter medication orders and data clerks type in handwritten physician orders, later to be signed off on – or approved on the computer – by the physician, often in groups of multiple orders at the end of the day. But if physicians don’t enter their orders themselves, they will miss out on the decision support built into the EHR system. The decision support, which is intended to help reduce medical errors, is one of the main reasons the federal government is bankrolling the incentive program.

Under the proposed rule, physicians are required to use a personal log-on to open the record and are also responsible for approving any information entered by others.

Some members of the committee were in favor of scribes entering only non-order data, while others were against delegating any data entry. But the major consensus among the group was that the physician is ultimately responsible for what is recorded.

Neil Calman, MD, president and CEO of the Institute for Family Health, said scribes could enter orders as long as physicians see the decision support later in the process.

“As long as the decision support appears at the time of authorization, the person who enters the order isn’t really that important,” he said. He added that it is common practice now for physicians to sign off on orders entered by other people.

But other committee members disagreed.

David Bates, MD, chief of research for the division of general and internal medicine and primary care at Brigham and Women’s Hospital, for example, said “I’ve looked at a lot of different systems and all of them deliver decision support at the time that you’re actually entering the order. I’m fine with having scribes with other things.”

Most of the physicians in the committee said it was not possible to have decision support appear at the authorization stage.