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EMRs and Templates: How to Avoid the Pitfalls of Boilerplating

Posted on October 10, 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.

On Kevin MD, there was a recent post about the problems associated with templating and John mentioned in his weekend EHR Twitter roundup. Some EMRs provide automation for notes so that a provider can check a few boxes regarding symptoms and have a patient note generated on the fly. While such a methodology works for a wide majority of patients a provider might see, it doesn’t for the one-off cases who present to the provider with certain problems and have something different going on. The author calls for a health IT products to function as decision support systems, meaning systems that allow for templating while at the same time encourage the provider to think through how a particular case might not fit the usual profile.

This study in Health Care Management Review pretty much comes down on templating. The study interviewed 78 physicians on how EMRs affect the skills of physicians. Yes, n=78 means we need to take this study with a pinch of salt, or more research is needed, but what’s revealed is pretty fascinating.

Physicians cut-and-paste too: Hey, I’m the last person to come down on using Ctrl-C/Ctrl-V. I’m doing it each time I write a blog post (albeit with attribution.) “A key dynamic with using EMRs involved the perceived ease by which a physician could use an EMR to “cut and paste” identical assessments of patients with similar clinical diagnoses or issues into several different patient records.”

It is better to get it “written” than right: Here’s something straight out of How to Write a Novel in 5 Days type self-motivation books. “The homogeneity of different patient visit notes convinced these PCPs that some physicians… favored the basic need to complete a patient EMR in a timely manner over the care management need to say something accurate and unique with regard to each individual visit.”

There’s way too much noise: Physicians interviewed recalled how specialists provided 6-8 line summaries of patients which contained everything a doctor needed to know about the patient’s visit – “[t]here was all signal, and no noise. Now as we review what specialists do in an EMR, and even what we do in primary care, what I miss is the narrative.” What you’re getting by checking a lot of boxes is copious documentation that says precious little, and makes you wade through the mire to get to the precious nuggets.

While I’m trying to poke some (I hope gentle) fun at the study’s findings, I’ve also been thinking along the lines of what features of an EMR system would help. One clue lies in the study itself: the physicians recalled how paper records forced them to dictate “certain amount of unique verbiage for transcription into a patient’s record.”

So maybe we need EMRs that:

  • combine voice recognition, so that the physician can continue to dictate patient notes
  • have Thesaurus like features to generate verbiage that at least uses interesting synonyms and phrases to give the appearance of uniqueness
  • don’t allow physicians to generate automated notes at all

What do you think will make things easier without boilerplating patient information?

Features of an EMR for Practical Use

Posted on May 28, 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.

For those of you who don’t read many of the comments on here and EMR and HIPAA, you’re really missing out. Some of the very best discussion and information comes out in the comments. At times I like to highlight some of the more interesting and thoughtful comments so that more people get to read them. This post is one of those comments where a doctor discusses the features that he believes should be included in an EMR that’s built for “Practical Use” as opposed to the meaningless “Meaningful Use.” I don’t agree with a number of his thoughts, but it does give you plenty to think about. I’m sure you’ll enjoy it!

Most of the charts look like:

Patient c/o cough.
HTN -controlled
DM – controlled
CHF – stable
No change in meds.

Those 5 short lines of text are the culmination of a clinical encounter and represent the result of a highly trained professional’s observations, conclusions and treatment plan. With the inclusion of patient name and date of service those 5 lines are the “Complete Medical Record” of that encounter. When Medicare or any other payer shows up to run a chart audit that’s all they want to see. There are certainly other documents like lab results that clinicians use in diagnosis and formulating a treatment plan, but those are simply part of the data “considered” by a clinician and are typically used once. That along with the more signifigant cognative data are processed through the clinician’s brain with the end result being output represented by those 5 lines of text.

When EMR products are designed around that work process EMR ubiquity is possible.

“Meaningful Use” is “meaningless” to clinicians.

“Practical Use” is easy to define, just ask a bunch of doctors who are resistant to the current generation of EMRs. What capabilities should an EMR contain at a minimum that would make it a “I’ve got to have that” clinical tool.

Here’s my list:

1. Must contain a textual clinical note.
2. Must contain a contextual/collaborative problem list.
3. Must contain a contextual/collaborative medication list.
4. Must allow access across enterprise boundaries.
5. Must not interfere with my existing documentation methodology.
6. Training should take no more than a coffee break.
7. Cost must be trivial like my cell phone service
8. Must not interfere with billing and administrative staff’s activities.

I already know how to write a clinical note.
I have finely honed cognative skills, don’t distract me from using them.
I already have a practice management and billing system.
I already get lab results electronically.
I already have e-prescribing.
I am not interested in drawing stupid little pictures on a screen with a mouse.

Finally an EMR must create a secure open channel of communication between clinicians.

I not going to spend $2,000 much less $100,000 to organize and share that information.

Doctors are not Technology Averse, they are Stupidity Averse.