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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

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

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.