Page 12 - Volume 69 Number 3
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Am I gaining insight into the patient’s problems? Or am I thinking about what a pain in the neck this EHR is and how frustrating it is to have to use 18 separate mouse “clicks” to edit and sign a clinic note and send it on to the referring physician. What I am most concerned about as I sit in front
of the patient and the computer screen should
not be whether I have fulfilled the documentation requirements to make the system happy and get paid for the visit. I should be concentrating on the care of the patient in the room with me, and whether I got it right, which is after all the real “meaningful” activity. Too often, it is only later, when I review the visit documentation before “closing” the encounter that I can actually concen- trate on the important stuff. Even as I do this I will be reminded of the meaningful use requirements
if I haven’t completed them yet: before I close the encounter, I had better “review” once again the smoking status of this patient who has never smoked a cigarette in his or her life.
The Current State of Affairs: Advantages and Disadvantages
The EHR in its current state of development is not a tool that will make physicians really want to use it. The people on top (CMS, the IT industry) are on the hook and have to make it look like it works, while the workers try to figure out how to make it actually work. Whether it actually helps them do their jobs, and convinces them that they are improving quality of care for their patients by embracing it is quite another question.
Nevertheless, there are some advantages to widespread adoption of EHR’s. It is clearly helpful to be able to quickly bring up a radiographic image to review the findings with a patient. It is clearly helpful to be able to look up old records instantly and to access chart information from other health systems that are now linked to mine electronically. It is clearly more efficient to be able to send communications to other providers electronically by secure e-mail or fax with 6 or 8 extra “clicks” on the mouse than to have someone generate and mail a separate snail mail letter.
It appears that another thing that EHR’s do well is to ensure that the requirements for billing are met. Much to the dismay of some insurers, aggregate billing has gone up as more physicians use EHR’s. This should have been predictable, because, the EHR has been designed to make it easy to create the documentation necessary to support level 3 or 4
or 5 patient visits by using short-cuts to fill in all the requisite parts easily by the use of templates and by pulling into the visit document information already in the chart elsewhere. (I foresee special audits on this activity in the future.)
There are significant downsides to using documen- tation designed for efficient billing rather than for good, efficient patient care. For one, the information already in the chart may not be accurate or up to date. For another, use of templates leads to inflated and sometimes grossly inaccurate descriptions.
This week I saw a template-based physical exam document on a severely developmentally impaired, non-verbal, wheelchair-dependent person with marked kyphoscoliosis that described the patient
as alert, conversant and ambulatory. Every visit now, even for a sore throat or a runny nose, can fill at least 3 pages with apparently mostly completely irrelevant documentation that maximizes reimbursement while also fulfilling the meaningful use requirements in a meaningless way. I can tell the difference between real and filler documentation, but the computer can’t. (Should we call these computer-generated “alterna- tive” facts?)
I don’t do a lot of in-patient care anymore, but every time I have a patient in the hospital I am reminded that EHR-based documentation for patients who are hospitalized offers all the same problems that I encounter documenting ambulatory patient care. First and foremost is the template- based daily “progress” note, which originated in part as a way to facilitate hand-offs while at the same time need to touch all the billing hot-spots, ensuring the proper level of complexity of care is documented, which repeats the same verbiage day after day in a way that makes it easy to make it look like the patient is getting cared for with the omission of relevant information about actual progress.
The same kind of insane repetitiveness is seen in the nursing notes, as a result of requirements to document everything about everyone every time.
If you have ever tried to review a chart that has been downloaded onto a CD, you will know what I mean. Recently I had to review an electronic record on DVD for a 6-day hospitalization that was 1,700 pages long! I yearn in vain for the days when a few simple narrative sentences on the paper chart told the story succinctly and clearly.
Somewhere along the line CMS (or someone) got the bright idea that in the interests of protecting patient privacy, only physicians and other health professionals could make entries into the electronic chart. Medical students have been excluded from
12 Washtenaw County Medical Society BULLETIN JULY / AUGUST / SEPTEMBER 2017


















































































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