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    It's time to get doctors out of EHR data entry

    There was a day when medical transcription was neat and clean. A doctor dictated what happened during an exam and a transcriptionist accurately typed each detail into the patient’s record. Each future encounter built on that record, a detailed history meant to ensure quality care. It wasn’t a perfect system, but it worked.

    Now, doctors sit for hours each week in front of a computer screen entering patient encounter data into electronic health records (EHRs). These complex systems were meant to more efficiently and effectively track health data for hospitals, payers, and physicians alike. And EHRs were promised to save physician practices, hospital systems, and other provider organizations millions of dollars in the long run.

     

    Related: Do I have to choose between an EHR and patient satisfaction?

     

    Reality shows something quite different. Placing documentation responsibilities on physicians is resulting in severe problems not only for doctors, but for patients and the hospitals/practices who serve them. According to a Northwestern University study, physicians with EHRs in their exam rooms spend one-third of their time looking at computer screens, compared with physicians who use paper charts who only spend about 9% of their time looking at them.[i]

    Doctors play an integral part in developing and maintaining medical records. But we are asking them to do too much, and the entire healthcare system is suffering because of it. Instead of dictating information into the medical record, many physicians are required to type notes into their EHR, which is time-consuming and distracting. That’s just one challenge they face when required to directly document into an EHR.

    Upon accessing the system, the doctor enters a patient’s medical number and their record pops up. There are boxes for history, medications, procedures, etc. This “structured data” methodology allows physicians to click radio buttons or check boxes to denote what was done, but too often allows for little or no free text. Physicians are presented options from which to choose, even if those options aren’t applicable. The structured data choices can’t be changed, and the patient’s record is built off what the doctor ultimately chooses as the lesser of evils. This type of documentation may work for someone with a specific problem, like bronchitis. But for a complex cancer patient who requires multiple treatment protocols, limited choices will hinder building an accurate picture of their care needs.

    Next: Patient focus should always trump data entry by physicians

    Marilyn Trapani
    Marilyn Trapani is president and CEO of Silent Type.

    8 Comments

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    • [email protected]
      I am not really sure that the article clearly spells out that Ms. Trapani is the CEO of a transcription company before someone actually reads the article. I am sure many wouldn't have read it!
    • [email protected]
      Dr. W Laurence and Anonymous are absolutely right and imposing requirements that serve no useful purpose for the goal of good patient care contributes significantly to physician burnout. When I was researching the causes of physician burnout for my book, Burnout: Prevention and Recovery, Resilience and Retention, it was abundantly clear that outsiders (regulators, insurers, med mal, etc.) are imposing their demands on physicians and interfering with their ability to provide care. In order to develop autonomous motivation (motivation that has energy behind it to accomplish the tasks), it has to be intrinsic, integrated, or identified (meaning the person can identify with the reason for it). This is based on a robust body of research by Deci and Ryan. Most of the EHR requirements do not meet this requirement. As a result, they contribute to the exhaustion component of the MBI burnout scale. Physician burnout has adverse effects on patient care and safety and costs. Physicians suffering burnout order more tests. Burnout co-exists with a lower than desired emotional state. Like all lower emotional states, it is associated with less than ideal behaviors and professional outcomes including: • Lower quality of care • Increased likelihood of errors • Increased likelihood of leaving the profession • Increased likelihood of turnover in search of greener pastures • Worse patient safety outcomes • Worsening relationships both at work and outside work, including increased divorce and relationship turmoil • Problematic behaviors including excessive alcohol and drug use • Suicide ideation and attempted suicide • Lower customer service scores • Worse response to workplace changes • Increased absenteeism due to increased susceptibility to colds, headaches, fevers, and chronic fatigue. • Decreased patient compliance with prescribed medications and follow-up appointments • Higher levels of general psychological distress • Decreased patient success in drug rehabilitation programs We would have a better healthcare system if we stopped imposing stressful requirements on physicians over and above the stress inherent in their occupation and provided advanced and transformative strategies to cope with stress.
    • Anonymous
      A chart note should not require the services of a scribe or a transcriptionist. The chart has devolved from a way to record information used to care for the patient and communicate with other doctors to a way for the government and insurance companies to mine for data that does not help the individual patient and because of inaccuracies cannot even be used to evaluate the management of groups of patients with the same diagnosis. The minutiae in ICD10 make the problem worse. The data needed to improve patient outcomes could be generated from a sampling of practices across the country. Pay them to do it. It's not necessary to have information on every single patient encounter in the country to do that. Meanwhile, an EHR that produced simple SOAP notes and was formatted like an old fashioned paper chart would be invaluable.
    • I decided I am going back to index cards
    • I decided I am going back to index cards
    • Anonymous
      Pie in the sky article. We doctors are responsible for the accuracy of what is in the data. We have all personally seen horrible and dangerous inaccuracies put in medical records by hospital employees, emergency room nurses, and yes, our physician colleagues. These are caused by people taking shortcuts, not updating previous histories and exams, and blindly accepting and copying the reports of others. Doing this is human nature. Everyone is too lazy and constrained for time. I left practice 13 months ago. I did not do the reports in the room with the patient. As a cardiologist with very sick patients, they needed my full attention. That meant that my notes were done at night and on weekends and I had no life. EHR's have been an abomination for MD's and were jammed down our throats by CMS, the insurance industry, and especially George W. Bush. Nevertheless, they are a fact of life now. If you are conscientious and want your records to be as accurate as possible, you need to do it yourself.
    • Dr. W Laurence
      I believe Ms T misses the main cause of so much note bloat. So much of what is entered into an office note serves no useful purpose other than to meet a Joint Commission requirement, a CMS requirement, or a reimbursement requirement. A typical office note does not really need a pain scale, a complete review of systems, a learning needs assessment, a falls risk, etc. But we put them in to at least earn a 99214 instead of a 99213 and to satisfy regulatory requirements, even though they are not contributing to the care and make it more difficult to find the important information in the note. Maybe we should be paid by the tenths of an hour, like lawyers charge. Nobody is telling them what they have to include in their client files. But, if our professional societies would fight back against these mandates, and require Joint Commission to prove both clinical and cost effectiveness before they impose a standard on us, and fight for payors to give reimbursement based on our work instead of whether we include a complete review of systems, then our screen time would decrease, our notes would be more concise, and we would provide better medical care.
    • Dr. W Laurence
      I believe Ms T misses the main cause of so much note bloat. So much of what is entered into an office note serves no useful purpose other than to meet a Joint Commission requirement, a CMS requirement, or a reimbursement requirement. A typical office note does not really need a pain scale, a complete review of systems, a learning needs assessment, a falls risk, etc. But we put them in to at least earn a 99214 instead of a 99213 and to satisfy regulatory requirements, even though they are not contributing to the care and make it more difficult to find the important information in the note. Maybe we should be paid by the tenths of an hour, like lawyers charge. Nobody is telling them what they have to include in their client files. But, if our professional societies would fight back against these mandates, and require Joint Commission to prove both clinical and cost effectiveness before they impose a standard on us, and fight for payors to give reimbursement based on our work instead of whether we include a complete review of systems, then our screen time would decrease, our notes would be more concise, and we would provide better medical care.

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