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Are EMR Templates Really That Bad?

Posted on December 16, 2015 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 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.

Recently, I read an interesting blog item by healthcare veteran Bobby Gladd, kicking around the notion of whether structured EMR data is killing medical practice. In the item, Gladd makes as good of a case as I’ve seen that while open text has its place, the lack of same is NOT single-handedly killing medicine.

In the blog item, Gladd ribs critics of template-driven medicine such as Margalit Gur-Arie, who has called structured data “the one foundational problem plaguing current EHR designs.” Gur-Arie argues that templated data controls clinical interviews, a phenomenon she calls “Bingo Medicine”:

“When your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say.”

Gladd does concede that templates for Meaningful Use can be “simply stupid,” for example in the case of the MU Core 9 measure of smoking status. But do free-written EMR entries support the care process better?  Maybe we do actually need “open-ended analytical narrative in the progress note, replete with evocative, dx-illuminating metaphors and analogies and elegant turns of phrase in lieu of blunt instrument categorical and ordinal ‘structured data,'” Gladd notes wryly.

Ultimately, perhaps critics of templates have gone overboard, the blog contends. Gladd suggests that Gur-Arie’s “bingo medicine” argument is more sound than substance: “I have to be a bit skeptical that (it) is anything more than a motivated-reasoning assertion of opinion lacking evidentiary underpinning comprised of adequate psychometrically valid studies of physicians’ cognitive processes while at work, perhaps using docs on paper charts as the differential ‘control’ group.”

As Gladd sees things, the real issue with templates isn’t their existence, as such. For one thing, as readers are likely to know, EMRs almost always come with free-text narrative options from many different points in the workflow. So it’s not that there’s no opportunity for clinicians to write detailed prose about their patient encounters.

Also, the issue isn’t necessarily that doctors are having templates forced upon them, either. As Gladd rightfully points out, at least the Meaningful Use-related data gathering requirements have been extensively vetted by the public, with each stage generating thousands of recommendations from physicians. And both CMS and ONC incorporated as much as possible from that flood of commentary.

Ultimately, the problem isn’t that physicians are being asked to adhere to digital documentation styles at times, Gladd contends. The true problem is the “productivity treadmill” requirements that push doctors to see 25-30 patients a day. “If the typical physician only had to see an average of one patient per hour…adequate documentation would be way less onerous,” Gladd concludes.

And there you have it. Overwork is the bane of any profession requiring brain work, and turning back to all narrative-style documentation does little to remedy the problem. (In fact, it could make things worse — for if doctors don’t have time to use templates, how good are their long-form notes going to be?)

Maybe templates have some downsides. In fact, if someone tried to get me to practice blogging with word templates I’d probably object. But it’s worth bearing in mind that template medicine may be a symptom rather than a cause.

Which Parts of an EHR Implementation Should Be Their Own Project?

Posted on September 29, 2014 I Written By

John Lynn is the Founder of the 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

A really great discussion has been started on this post about staged patient portal implementations. Here’s one comment that really struck a chord with me:

I think that on a lot of strategic roadmaps “patient portal” is listed as a goal…a one time deadline without understanding how the patient portal works; what information flows into a fully functioning portal and to the patient; and what the system, risk, and security requirements are to consider.

This will require C level suite and decision makers to ask questions that might be getting them “into the weeds” a bit or questions that they may not know to ask. This is why a several strong consultants that are specialists in individual subject matter might be needed – instead of one project manager expected to move the project plan forward on the road map and to know everything.

This comment is right that the patient portal is often seen as a line item on a project plan that just needs to be completed. That couldn’t be farther from the truth. As one person said, sometimes you can get a grand slam, but most of the time you have to do a bunch of little things along the way. A patient portal is a great example of this. You don’t just implement a patient portal one time and then it will run forever. There’s more you can do to leverage a patient portal for your institution.

Are there other parts of an EHR implementation that exhibit similar characteristics? Maybe you implement them, but there’s always more that could be done to improve its use in your organization? Templates and workflow are one that come to mind. There should be an ongoing evaluation of your templates and workflow in order to ensure that it’s as optimized as possible.

What other pieces of your EHR project could benefit from a separate staged project plan? Of course, this assumes you’re starting to think more strategically than just trying to check off the MU check boxes.

Most Doctors Manually Code Despite EHR Automated Coding

Posted on July 17, 2012 I Written By

John Lynn is the Founder of the 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Pamela Lewis Dolan has a great article in AMA’s American Medical news about the automated E&M coding using an EHR versus manual E&M coding. Here’s a quote which sums up the article:

The Dept. of Health and Human Services Office of the National Coordinator for Health Information Technology asked the Office of the Inspector General to prepare a report looking at how Medicare physicians use EHRs to assign and document codes for E&M services. The report found that 57% of Medicare physicians use an EHR, and 90% of them use their systems to document E&M services. But most physicians still assign those codes manually, which could mean they are undercoding services that could qualify for a higher pay rate.

I’ve started seeing more and more people talk about this subject. It’s an amazing switch since one of the initial selling points of EHR software was this powerful E&M engine which would help them to ensure that they’re coding their office visits properly. In fact, many argued that with an EHR they were able to code at much higher levels than they could on paper.

In some ways, I think this can still the case if done right. The rationale is that many times a doctor would evaluate something on a patient, but not take the time to document it in the paper chart. Since they didn’t document it on the paper chart they couldn’t code for it. I’ve heard doctors say that thanks to quality EHR templates they’ve been able to document more of those “extra” items and so they can properly justify the higher code.

Obviously there are a lot of questions and risks associated with what I describe above. The most important being that many achieved the above result by using blanket templates which even included things that they never actually evaluated. There is a lot of talk about these blanket templates being a high risk during an audit.

Although, what I think the above quote highlights is something that I’ve seen regularly in healthcare. Many doctors are chronic under coders. I think this other quote from the article linked above explains why many doctors under code:

“If you do a cost-benefit analysis, it might be less expensive to undercode than try to deal with an investigation,” she said. But Fenton has found that there doesn’t have to be a large increase in coding levels to see a significant bump in revenue.

I’m sure there are many reasons that doctors under code, but this could be the largest one: fear. The fear of an audit uncovering over coding is real and palpable. Plus, an EHR automated E&M coding engine doesn’t solve this problem for a physician. At the end of the day the physician is still responsible for the coding, not the EHR software.

Fixing EMR Drawbacks

Posted on October 17, 2011 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

FierceHealthIT editor Ken Terry had a recent post on the need for better human-computer interfaces in EMRs. He highlighted a few areas where EMRs could stand some improvement, and I thought they were bang on. These are aspects I’ve thought about a great deal myself, and true to the Steve Jobs dictum of staying foolish, I’m offering some solutions to these oft-mentioned problems. I’m sure there are plenty of people who have already thought of these and better solutions, but here we go:

1) Initial Data Entry – The biggest headache for providers’ offices today is what to do with all those boxes of medical records. Scanning solutions exist but they leave you with unstructured data. Manual extraction is time-consuming and requires upfront investment. I’ve pondered for a while about this. I think on-demand data extraction might be the way to go. Provider offices know ahead of time what their weekly, even monthly appointments are. If a provider’s office digitizes the records of patients with upcoming appointments every week, it should have most of its records digitized by end of year. This is assuming patients make it to the doctor’s office for at least once-a-year appointments if not more. If the office outsources this work, it needs some monetary investment, no doubt, but such a setup might be affordable since it is pay-as-you-go.

2) Templating – Terry states that many doctors hate the templates that come with most EMRs. And templates make it easy to generate pages and pages of verbiage which say exactly the same thing for patients with similar profiles, or say very little that is meaningful. Surely customizable or extensible templates can get rid of this problem. Or speech-to-text dictation that allows the doctor to mirror practices from not so long ago.

3) Alert Overload – Many EMRs are designed to issue alerts for adverse drug interactions, prompts for patients and similar such decision support tools. But too few of these and you risk not asking the right questions. Too many providers just ignore them, or worse, override them. No easy solutions for this one, except maybe to figure out where the fine line lies between lack of decision support and too many alerts.

4) Interoperability – EMRs cannot talk to each other. So a patient who moves from one provider to another is really at the mercy of software whimsies. Or worse. For providers, it’s equally frustrating not to be able to get ahold of the patient records in a format suitable for their particular EMR software. One simple answer – standards. Granted HL7 is still evolving, but EMR vendors need to at least consider offering data exports in this format.