The EMR template: I want to believe

The X-Files fans will remember the poster that Agent Mulder had on his bulletin board with a picture of a flying saucer and the words, “I want to believe.”  That’s how I feel reading EMR notes sometimes.  I want to believe, but I doubt.

I know how this happens.  The EMR vendor, the practice implementation team and the doctor have a meeting to develop the “normal” template for a hospital admission or a diabetes follow up visit.  I myself may have participated in these meetings.  Let’s use the admission as an example.  We want to develop a template with a comprehensive exam, so that it will meet the requirements for a level two or three admissions. The coding specialist hastens to add that not all admissions are high level admissions, but if the admission is complex, we don’t want it to down code based on missing one exam element.  The template is done, and the doctor never looks at again.  The doctor never reads, line by line, the admission note that s/he generates using the “normal” exam template.

The results:

  • 86-year old woman admitted with a small bowel obstruction with “gait—non-antalgic.”  Really?  The doctor had the patient get up off the gurney in the ED and walk?
  • Normal external ears for a non-ear problem.  I know: it’s a bullet on the 1997 exam, but have you ever documented it before?  Don’t do it unless it’s relevant.
  • A toddler with normal insight and judgment.  My toddlers didn’t exhibit insight and judgment, but maybe they were backward.
  • A seven month old seen in follow up for otitis, who has no carotid bruit or JVP.
  • Abdominal exam normal, “with normal surgical scars, if any, as described in history.”
  • The same exam for all problems.  I mean, the exact same exam for all problems.

The same difficulty occurs in the ROS, using a “normal” ROS exam.   Use caution with the use of these normal templates.  In the history section, contradictions in the HPI and ROS are particularly troublesome.  For follow up visits, you don’t need a complete ROS except for a 99215.  99213 requires only one system in the ROS and 99214 requires only two systems in the ROS.

What to do?  How to make the best use of EMR, take advantage of their time saving features (I know, almost an oxymoron, but there must be some—I want to believe) and not produce cookie cutter notes?  Here’s my advice:  document what you would have documented when you dictated records.   Don’t do a complete ROS for every follow up patient.  Print out and read line-by-line a sampling of your own notes.   Have different exam templates for different problems.

Your history of the present illness should have more characters than a tweet and contain at least as much information.  If it is too difficult to free text what brought the patient to the visit and to describe the symptoms, insist on dictating that crucial information into the record.

Physicians sometimes blame us for their EMRs.  “You made us use these systems.”  “Health information tells me that has to be in the note for meaningful use.”  Health information won’t be responsible for the repayment if a payer comes calling.   No one in health information has a provider number: the clinician’s provider number is on the claim form.  Take responsibility for both the information and the format and insist on a format that makes clinical sense.

Betsy Nicoletti is President, Medical Practice Consulting and author of Auditing Physician Services. She blogs at Nicoletti Notes.

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  • Beau Ellenbecker

    All of this would be solved if we weren’t billed based on bullet points. Why did the providers before us not fight that implementation. Why is a medical record now a billing device?

    • NewMexicoRam

      Why is the medical record a free trough for attorneys?

      Doctors let everyone else determine health care long ago.

    • betsynicoletti

      I think there are two separate issues: the quality and integrity of the information in the health record and the billing requirements to submit a level of service.

  • Docbart

    Or just say “no” to EMR and try this new analog alternative. Try it. It feels good. Look at the patient while you converse, instead of looking at the computer. Write a note that is completely relevant to the visit and be done with it when the visit is over. Never have to go back and work on your notes after patient hours. Don’t pay thousands of dollars to acquire and service a system you don’t need. Never be crippled when your system goes down. This system never does. The new alternative is paper charts written with pens! Imagine that!

    • drg

      Wow! Novel idea. That’s what I’m doing. Until they take my pen away….

      • betsynicoletti

        Why can’t the physician dictate a note, and have someone place it as a flat document into the EMR? This would preserve some advantages: lab results easy to find, up to date (we hope) problem and medication list, but the individual with the highest education in the building doesn’t have to type. And, covering clinicians could tell what happened at the visit.

        • drg

          I think we all appreciate your article. I guess the idea is that the EMR was really made for billing purposes not to improve communication of clinical notes. But I like your idea.

        • Docbart

          Some physicians do dictate notes. It is a bit costly, but legibility is enhanced, which is sometimes an issue, especially in group practice. The big issue is that EMR software uses templates and is designed to have the doctor cover certain points to justify a billing code. It also pulls into the note a great deal of data that is not really relevant to the core content of the note. Dictating or writing notes does not use that template.

          If dictated notes were entered into the EMR, then there is still the expense of that system, fallibility and security issues that don’t exist with paper chart systems. The doctor is then either dictating in front of the patient, which can constrain what the note says, or dictating after the visit, which is less accurate and efficient.

      • Docbart

        They’ll have to pry mine out of my cold dead hand.

        • drg

          Zing! Good one.

  • Margalit Gur-Arie

    So basically, the advice is to find ways to bypass the automation in the tool and document as you did before you purchased the tool, with the added inconvenience of having to carry the tool in your other hand?

    • betsynicoletti

      My preference: have the doctor dictate the HPI and comments into the assessment and plan. It is ironic, and I like you analogy of a car that requires the use of horses. I do sometimes talk to clinicians who say they like their EMR, they finish their notes at the end of the day and they would never want to go back to paper. But, that is the minority. The majority say it slows them down, and makes their lives more difficult.

      • Steven Reznick

        I have an elderly practice. I do not enjoy dictating in front of them. They do not understand or hear what I am saying and it adds to their angst and confusion. Even with training , the voice recognition software is less than perfect. If the EMR manufacturers and vendors were offered a $44,000 bonus over 5 years and forced to reduce their charge for the system by that amount until the providers achieved meaningful use then the EMR training would have been on site and flawless. The help call centers would have been in Silicon Valley or its equivalent. Instead the incentive ARRA law was passed with a buyer be wary attitude for physicians and providers. We speak to call centers in Asia who rarely can handle our needs in a timely fashion. The drug and eRX software is a separate package within the medical record software requiring calls to different help centers.. Having mastered MediNotes it was sold to Ecclypsis ( new software) only to be sold to All Scripts ( new Software) only to have All Scripts announce they are moving to a new platform ( new software). Each change involves new training for office staff and personnel and the conversion of existing medical records to a recognizable and retrievable format something none of the previous vendors have done well. Couple this with having to learn different computer order entry software at each hospital you are seeing patients at and you know why doctors are fuming. Yes as a touch typist I love the ease of reading meaningful notes and customizing my notes but realize the time and effort and cost of getting to that point only to have the software change again. All the money invested in this process , at a time when the varied systems still do not communicate with each other would have been far better spent on providing direct patient care. Once again the marriage of government regulation and big business created big bucks for business at the expense of the patients and providers.

  • betsynicoletti

    Most of the physicians who have commented agree that the EMR slows them down and is difficult to use. Dictation once an EMR is purchased is costly, even if used not to replace the EMR but to provided added clinical information. From a billing perspective, auditors complain that they find it hard to separate the wheat from the chaff, and accurately select a level of service. It is easy to criticize, but what are the solutions?

    Where are the answers, solutions and suggestions? The ones I have are not in the spirit of EMR, perhaps:

    1) A clinical, non provider staff member such as a nurse should enter in all past medical history. I hear from physicians that pre-loading is done poorly, if at all, and that they are literally typing in that information in order to assure accuracy. Can we just say no to that?

    2) Allow the physician to dictate key elements into the EMR. I know this needs to be selective because of meaningful use requirements.

    3) Prior to a visit, ask the medical assistant to print out the key information the physician needs such as medication list, problem list, results of previous diagnostics, health maintenance summaries so the physician enters the room without having to look up anything. Those first (however many) clicks that were accomplished with a minute of looking at the paper record take time. And, are usually the first thing the doctor does entering the room. If that were reviewed quickly outside the room, the first thing the doctor did would be look at and talk to the patient, not interact with the computer.

    4) The technical types among us must be able to provide some helpful advice for the solution of having 6 different log in names and passwords to access the multiple programs and diagnostic results/order systems required in a single day.

    • Steven Reznick

      By printing out key information in advance and placing it on the patient chart aren’t you defeating the goal of going paperless?
      All of these problems have been created because the reimbursement for primary care necessitates seeing many patients in a shortened time period to generate enough revenue to cover the overhead. Maybe the answer is for the technical types to demand of their legislators and insurers adequate compensation for primary care evaluation and management services so the clinician can spend enough time with the patient to be thorough and document thoroughly and individually in the electronic format?

    • Eliz Hipp

      “Dictation once an EMR is purchased is costly….”

      Not more costly than before it was purchased, and certainty less costly than having a doctor type their own notes. It’s a simple matter of doing a cost/benefit analysis to see if it’s worth it for your practice. Would you make more money, overall, if the doctor saw 1 to 3 more patients a day instead of spending an hour typing notes, factoring in the cost of transcription?

      • southerndoc1

        For most docs, the cost/benefit analysis will show that the best bet is to stick with paper and see one more patient per month to cover the CMS penalty.

        • Margalit Gur-Arie

          I’m sorry for the irreverence, but who cares?

          Document any way you feel is right for you: dictate, write, type, click…. Why are we micromanaging and wasting so much time on how to take notes? They are just notes, right? EMRs are out there now. Obviously they are not helping much in this iteration. Use them if you want to and don’t use them if you don’t.

          Meaningful Use is voluntary and incentives/penalties are minor. E&M coding was formulated in the nineties, before EMRs had any significant adoption. You used to bill back then too. How did you manage that? Do the same now…

    • Shirie Leng

      Amen sister to number 4! Good post, great discussion.

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