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

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.