Given all of the recent hubbub regarding cloning of medical office notes using electronic medical records systems, I thought I would write in with my opinion on this topic. You know, just as one fabulous new technology comes about that enables much more efficient documentation of patient encounters in physicians offices, it seems like critics are quick to try to take away that ability from doctors. Most doctors work hard at what they do and are just trying to do a good job in providing the best of care using all the modern digital tools available.
Since there are no official published guidelines in this area, it seems yet another of many many MANY (did I mention many?) gray zones in the world of digital and mobile health technology.
Like it or not folks, the cut-and-paste function available on any computer is here to stay. It’s up to physicians and other providers like nurse practitioners and physician assistants to choose to use this technology responsibly. Furthermore, I believe that it is not impossible to do so. That would only be logical. Otherwise, we could never acquire anything that made our lives as providers a little easier.
I understand that the Medicare system is practically bankrupt as it is and seeks to minimize fraudulent payouts. I also recognize that there are nefarious individuals out there posing as medical providers who can crank out EMR notes that are identical in a mass-production fashion in order to financially rob the system again and again.
However, let’s not take an anti-EMR philosophy. Let’s not throw the baby out with the bathwater. I don’t have the perfect solution, but rather then forbidding medical providers to use the technology in a powerful way to see more patients with less busywork at the end of the day that does not benefit patients whatsoever, I think we need to put more thought into solving this problem. What do they expect doctors to do with EMRs anyway? Write everything from scratch every time? Such an approach would be both nonsensical and naive. And the solution should not be to withdraw the technology or force doctors to do things that are unconventional.
On the contrary, we need guidelines that make sense and do not add needless work to already harried medical professionals. We need simplicity and not complexity. We should not seek to recreate the debacle that some people came up with long ago that is the tax code-like nightmare of Evaluation & Management (E&M) guidelines, which are still quite gray in many areas. We need to be able to empower doctors, NP’s and PAs even further with technology rather than retract abilities that the technology enables.
I’m purposefully not getting into specific examples in this post for the sake of brevity. But I’ll be happy to take any questions my readers may have. Who knows, it could lead to interesting future discussions. For example, the precise definition of “cloning notes”, what qualifies?
The whole premise or underlying purpose behind cloning, templates, default phrases, default sigs, etc. is to allow the providers to spend more time with hands-on healthcare and face to face discussions. It should not be an outlet to skip accurate charting but we know that will be the cost for some.