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Adding “Social Documentation” To EMRs

Posted on March 11, 2013 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

While EMRs store key clinical information, a vast amount of clinical communication goes on outside the system, via instant message, text, e-mail, fax, phone and social media.

Most health IT managers don’t concern themselves much with the chatter outside the EMR, other than to see that — where possible — it takes place in a secure manner. But according to John Halamka, MD, chief information officer for Beth Israel Deaconess Medical Center, this communication is too important to be ignored.

Rather than let these conversations stream on without ever entering the EMR, he argues that it’s time to begin mining these discussions and integrating them into the EMR.  As he sees it, smart devices, the cloud, instant messaging, SaaS and social networking should be combined to create what he calls “social documentation” for healthcare.

Just what is social documentation?  Here’s his definition:

I define “social documentation” as team authored care plans, annotated event descriptions (ranging from acknowledging a test result to writing about the patient’s treatment progress), and process documentation (orders, alerts/reminders) sufficient to support care coordination, compliance/regulatory requirements, and billing.

So, in social documentation, the various channels clinicians are already using to connect with each other go from ancillary information to key ingredients in a team approach to care. But Halamka breaks it down further. Social documentation, he says:

*Incorporates data input from multiple team members, reducing the documentation burden for each participant
*Eliminates redundant entry of the same information by different caregivers (nurse, pcp, specialist, resident, social worker)
*Supports Wikipedia like summaries (jointly authored statement of history, plans, and decision making)
*Supports Facebook/Twitter like updates i.e. “Patient developed a fever, ordered workup, will start antibiotics”
*Incorporates data already present in the EHR such as orders and results without having to re-describe them in narrative form

I don’t know about you, but to me this makes enormous sense. As Halamka himself concedes, creating a new modular architecture that can support such documents might be “burdensome” but it’s still something to bear in mind as we move forward.

What Are the Problems with EMR Documentation Today?

Posted on October 29, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

While at AHIMA 2012, I asked Susan Sumner, Executive Vice President of Ambulatory Services at Accentus Inc. about some of the problems with EMR documentation today. Here’s her video answer with her views on narrative EMR documentation vs point and click EMR documentation:

Interoperable EMR, EMR Documentation Time, and Physician Happiness

Posted on October 7, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This week’s look around the EMR Twitter world seems to indicate a growing number of people talking about the challenge of EMR in its current state. I guess that’s one challenge of wider spread adoption: more people talk about its weaknesses. Although, in the end, we need to have these important discussions. So, it’s good that we’re hearing these concerns voiced.


This is one of the biggest complaints that I hear over and over with EMR. It’s very true that the EMR information isn’t really portable. I think we’re making some progress on this, but it is still a ways off from where it could be. What I don’t think most people recognize is that getting all these doctors on EMR is a necessary step to doing all of the patient data portability stuff. It was never going to happen if doctors didn’t get their records electronic.


The challenge of an EMR “slowing down” a doctor is a big one. Although, as is discussed in the next tweet, there’s a new generation of EMR that take this into account. Plus, there’s a whole shift in this discussion. Before it was like force feeding doctors on a template based system. In some cases we’re still seeing this, but becoming more common is the approach of allowing for multiple options that allow a doctor to work the way that’s best suited and most efficient for them. This will take some time to play itself out though.


The general idea of this article is good. It says basically that the first generation of EMR software was focused on replicating the paper process in electronic form. Then, it suggests that we’re seeing the next generation of EMR software which is working on “physician happiness” and “physician productivity” and this is producing a much different workflow. Change is hard though, but I think it’s happening. Of course, my biggest concern in this regard has to do with EHR certification/Meaningful Use and hospital acquired practices stifling companies that are part of this second wave of EMR software.

EMR Doctor’s Blog: Popular Misconceptions of Using an EHR System From a Provider’s Point of View

Posted on December 6, 2010 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

I thought it would be fun to discuss the “real world” of what it’s like to use an EHR system. Here are a few misconceptions that, if you believe all the advertising and other hype, you might have about the benefits of using an EHR system. Although the promise is definitely there in terms of what should be feasible ideally, the real world often determines otherwise.

Misconception 1. “I walk out of the office at 5 PM with all of my notes done for the day.  Awesome!”

Maybe once every month I can do this, on a slow day. The fact is that all of the documentation that needs to be completed prior to signing a note usually cannot be done for all visit notes by the end of the day. There are a variety of issues. Patients throw you curve balls on the way out the door. Patients have complex issues that you need more time to research prior to finalizing your plans. Patients forget information that they want to call you back about later, e.g. missing medication names and doses, doctor’s names that they want you to cc:, etc. On busier days, when patients come in late and you end up juggling appointments to avoid refusing to see anyone (this is private practice with real cash flow needs after all!), or when the phone just ends up ringing off the hook with one urgent issue after another, signing all your notes by 5 PM becomes impossible.

Misconception 2. “It’s a breeze to electronically send all my prescriptions. I don’t need a scrip pad anymore!  Woohoo!”

Mail order pharmacies destroyed this one with all their forms. Three-quarters of the patients in this category need me to fill out a paper form to fax in. The other 25% need paper scrips written out, typically five to ten at a time, so that they can mail them in themselves. Auto-renewal requests come in by fax every day, needing to be filled out and faxed back. My personal revenge comes in the form of being able to fill most of these out using my PDF editor software prior to faxing them back without touching a single microdot of ink to paper.

Misconception 3. “I don’t have to dictate anymore.  Yippee!”

For all new patient visits, I end up dictating at least the history of present illness (i.e. “HPI”, the first paragraph or two telling the patient’s story for those of you unfamiliar with this terminology). Although I can eliminate paying for this service by using a free iPhone app (Dragon Dictation), I still have to go through the process of speaking and then editing the notes. The alternatives would involve me sitting there wasting huge amounts of time typing details into a paragraph or two for each patient, or I would end up doing what I see some of my referring docs do, which is to type in VERY brief notes that eliminate a lot of important details just to get by and move on to the next patient. Some contrarians might suggest that everything can be done through templates, which is partially true to some extent, but everyone’s story is unique and different, especially when you are dealing with subspeciality areas such as disorders of the thyroid and adrenal glands.  The last time one of my patients had run-of-the-mill chest pain that could be reduced to a series of templated checkboxes to adequately describe their story was … well… never.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009. Check out all of Dr. West’s EMR Doctor’s Blog posts.

EMR Doctor’s Blog: When does efficiency in documentation become misguided and counterproductive?

Posted on November 29, 2010 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

We have all seen medical records from an emergency department (my apologies to the blissful ignorant out there — you don’t want to know if you don’t already). Much like sausage, they come out pretty much all ground up, full of information that at first glance can be difficult to figure out. If you find yourself asking questions such as, “Where is the part about why the patient came in and what the doctor thought about their case?” then you just might have one of these notes. They’re actually one of my favorite types of “old medical records” to sift through for the purposes of “reviewing and summarizing”. This is because when you’re dealing with gobbledygook, well, there’s not much to summarize. It’s easy to flip through forty or fifty pages in no time and say that you have honestly reviewed and summarized the old records, which are full of near meaninglessness that doesn’t impact my decisions in the patient’s care much, if at all.

The ER notes (and many primary doctor visit notes nowadays) result from having programmers who don’t appear to understand the appeal of a well-written note in facilitating basic communication. Computer programmers who get their hands on the list of required information that must be put into a note to pass by insurance standards don’t always design good products. Unfortunately, this really only highlights the insanity of criteria for medical documentation to gain the golden eggs of insurance company reimbursements for providing medical services. I’ll save those crazy criteria for some other day. Nonetheless, the tax man and the gobbledygook cometh. If only they had the guidance of a practicing physician in the design process!

Unfortunately, as the gold rush for economic stimulus dollars ramps up, poorly designed systems will most assuredly continue to be thrown onto the market. I recommend to anyone considering incorporating an EHR system into your practice that you actually consider and request to review a sample of the output format. If it looks like something that would embarrass you to show your former mentors from the residency or fellowship program in which you trained, then I would posit that this is probably not fit for medical documentation. If no one wants to read what you wrote, then is it really worth doing? And please don’t be fooled into thinking that spending more money is the key to getting a better product. Ask the EHR vendors to put their money where their mouth is.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

Doctors’ Documentation Methods Not Ready for EMR

Posted on February 27, 2010 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

An interesting link came across my twitter stream tonight that suggested that doctors aren’t ready for electronic medical records. Here’s a short section that basically captures the bloggers point:

Last week, a blog in the Houston Chronicle cited some staggering figures about the Texas Medical Board’s announced disciplinary actions against 70 doctors, 12 of whom were in the Houston area alone.

Of those 12, nine lost their licenses, were financially penalized, or are required to attend training because of their lack of proper medical record keeping. Four actions were specifically related to failed record-keeping practices.

And this isn’t the first time this has happened in Texas by a long shot — in November 2009, 75 actions were taken against physicians, and 28 of those were related to improper record keeping.

Hopefully, Texas will set a precedent and other states will start taking a harder look at this issue, especially with the pending incentives to increase the use of EMR/EHR.

I think this points out what I (and many others) have said previously, however: Simply moving from physical-format records to electronic records is not going to improve the quality of diagnostics and healthcare.

I personally am not convinced that this really matters. In fact, if anything an EMR will expose those doctors who have poor documentation methods. I think that’s a very good thing to have happen. I want them to be exposed and held accountable for their poor documentation. That’s better for the healthcare system as a whole.

One other interesting part of the article was that it said that the “punishment” for some of the above violations was being required to attend a CME training for medical writing. Next up is a CME training for medical writing in an EMR?