Folks, tonight I hope to nudge everyone who reads this to realize that they’ve got a problem to solve. The problem: How you’ll get doctors interested in using that pretty EMR you bought. I mean fully use, not just do the minimum, to the point where your institution can do something with the data.
As readers know, data collection requirements are mounting as Meaningful Use requirements phase in. And patients will get more chances to review that data over time. You want the e-charts not only to provide a basis for good care, but also meet regulatory requirements, participate in health plan programs and even offer consumers a nice glimpse of reality through soon-to-emerge patient portals.
The thing is, here at HospitalEMRandEHR, we’re hearing increasing noise about doctors who, under tremendous stress, are essentially cutting and pasting background info into templates. This is a Bad Thing. Data paired with observations in text areas produces a meaningful package; data packaged with boilerplate language may translate into pages of almost worthless content.
You know, even if your doctors aren’t offering as much context on patients as they used to, the charting they do may be good enough to scrape by and get MU incentives paid to you. The doctors may still provide enough information to convey the sense of what they did to others, and follow up too.
That being said, it just doesn’t make sense to accept the bare minimum when you’ve spent so much, and ultimately, hope to see clinical improvement as one of the payoffs from your EMR investment. So, bear in mind that you don’t just have to win over physicians to tolerating EMRs — you’d better be sure they’re willing to adapt to EMRs culturally, which means that they figure out how to produce value in an EMR-based record.
If you’re thinking “Hey, I’m not sure how to do that myself,” then figure it out, hopefully after having good talks with thought leaders on your medical staff. Create some standards for creating a rich EMR record and encourage physicians to support their colleagues in creating them. After all, the last thing you want is to demand one more thing from your doctors if you’re not sure yourself what you want.
This issue is more complex than can be covered here. It turns out there are large bodies of text that can, and should, be copied and pasted. The patient’s family history, for example. If a patient’s father died of pneumonia, should I check with the patient to see if he came back to life and later died of something else? The HPI, however, must always be generated de novo. Ditto for medical decision making. But bringing past information forward in the context of a new visit not necessarily a bad thing. It all depends on which information.
Brian, of course you’re right about history. The issues I’ve been hearing about involve physicians copy-and-pasting clinical summaries regarding current events, though I’ve never seen it directly. I’m not sure exactly how that works, though; would you or another reader be able to provide an example of the “bad template use” some physicians have cited?
Copying forward a physical exam or review of systems can lead to documentation of a normal finding when, in fact, it wasn’t examined. As you mentioned, I’ve seen examples of systems that give you a template for the HPI–always a bad idea. HPI’s are unique, like snowflakes.
In my opinion, you can copy forward PMH, Meds, Allergies, FH, SH, and you can template the PE and ROS as long as you can easily edit what you pull forward. You should never be able to copy forward HPI or medical decision making. Haven’t seen a system that finds the right balance. The Hospital EMRs seem to lean too far to no copy-paste functionality, and the BoB EDISs lean too far toward the import-everything mentality. I have even seen documentation systems (won’t name names) that bascially just give you a whole note (i.e. Chest pain) and you have to go through and edit everything that isn’t true. This is just crazy. If you miss something, you have documented a falsehood by default.
If you want clinicians to put thoughtful context into their EMR notes, the first thing you have to do is eliminate the notion of the 8 minute office visit.
This is just one of the great many contradictions we are forced to endure by our over-regulated system.
HIPAA mandates a very high level of data security. HIEs demand a very high level of data transmission which is stymied by the security demands of HIPAA.
EMRs require a slow and laborious process of hunting and clicking and typing in order to enter complete, meaningful, contextually accurate data. Health economics demands an 8 minute patient visit.
CPOE demands contemporaneous entry; DSS interrupts the process. Now the FDA (or someone) is going to start regulating this aspect of EMRs.
Patient experience scores demand congenial, cheerful clinicians. The realities of medicine demand the delivery of somber, life changing news in highly stressful situations.
Each of these contradictory demands places the clinician in a position of being forced to choose what’s best for the patient or what’s best for him/herself. In the bad old days, the clinician could afford to put the patient first. Today, s/he may jeopardize his/her job by doing so. Do we go with cheerful expedience, or responsible difficulty?
The article and comments thread lead to one conclusion: The basic fund of knowledge required to fully bring the information age to our health care system does not yet exist.
Our practice has been using EMR successfully since 2005. We became MU compliant this past October 1. The challenge is similar to what you would face if you were trying to get a Model T Ford to go 70 mph on the interstate.
The IT community and the heath care community are still not communicating well. The products we are forced to use are the technological equivalent of B & W TV sets or brick cell phones – they fill the space but simply don’t work well enough. The IT folks still don’t get it.