The electronic health record (EHR), an essential aspect of health information technology (health IT), serves multiple critical functions in modern healthcare. As a real-time information tool for longitudinal patient care, the EHR serves as a centralized digital repository to collect, preserve, and access patient data, including structured values, clinical notes, and interpretations of radiology and pathology tests.1
While this comprehensive documentation is essential, EHR functionality has extended beyond record keeping. For clinicians, the EHR is a central platform for aggregating, organizing, and visualizing diagnostic information. It facilitates clinical reasoning, record management, and communication with the care team.
Advanced tools for knowledge sharing and generation provide decision support through alerts and embedded clinical decision support (CDS) systems that have a significant role in diagnostic safety. EHRs enhance patient safety both directly and indirectly by improving data documentation, ensuring data completeness, and supporting the long-term sustainability of patient records.2
The potential value of the EHR to support improved patient outcomes, enhanced patient safety, and reduced costs has only been partially realized as current EHRs present both challenges and opportunities.3-5 An often overlooked potential benefit of EHR adoption is its role in documenting the diagnostic process and essential variables related to the patient’s diagnostic journey. Diagnosis serves as the cornerstone of patient care, providing a roadmap for treatment, monitoring, and decision making.
Errors in the diagnostic process can occur at various stages, from initial patient presentation to the final diagnosis, and can stem from multiple sources such as cognitive biases, communication failures, and system-level issues.6-9 Documentation of diagnoses varies significantly by provider, practice, and disease, leading to challenges in diagnostic accuracy, clinical variation and management, and communication with patients and care team members.10-13
In the digital era, accurate and comprehensive diagnosis documentation within EHRs is paramount, not only for the continuity of care but also for ensuring patient safety, quality of care, and effective healthcare delivery. Documentation tools such as templates, smart phrases, and voice recognition software provide features to increase the quality and utility of clinical documentation. However, these tools require appropriate management, guidelines, and oversight ranging from internal policies and procedures to federal regulatory compliance.
The 2017 narrative review “The Impact of Electronic Health Records on Diagnosis” explored how the EHR facilitates diagnosis and improves the diagnostic process, as well as the major ways it is problematic.14 This issue brief reviews the history of documentation legislation, including rules and regulations, and outstanding challenges and best practices to improve documentation. It also identifies future developments and opportunities for improvement, including emerging technology-based strategies to improve the traditional documentation process.
