EMR tips for locum tenens doctors

If I’m learning anything from working locum tenens jobs, it’s that there is a wide, mind-numbing variety of electronic medical records (EMR) systems in place around the country.  At my primary work site, we use Med-Host.  Like every EMR, it has some bugs. But having seen other systems in other places, it’s clearly a Cadillac product in a great, big car lot of Yugos.

I’m not going to disparage other systems by name.  That would be rude and unprofessional. But some of the EMR products out there are simply, well, cumbersome to say the least.  In point of fact, while paper charts with check-boxes aren’t perfect, and don’t tell the story very well, they do allow one to move fairly quickly between patients without log-ins, log-outs, screen changes, and endless highlighted, required fields.

My problem with EMR as a whole is that it isn’t really designed for the good of the practitioner or the patient. It seems to exist to capture data and expedite billing.  Anyone who looks over an EMR generated chart will find to their dismay that the layout makes it very difficult to interpret what happened.  Sometimes it makes it difficult to even find the chief complaint in the sea of screening exams, re-examinations, pain scales, and whatnot.

But I digress from my point.  If you are going to take a locum tenens job, it is a good idea to learn as many systems as possible, and make that known on your CV.  When deciding which doctor to hire, it just makes sense facilities will choose the one who knows the system and will be easier to integrate into shifts.

Furthermore, if it’s possible to dictate notes into the EMR system, by all means dictate.  It allows you to tell a story, and much of medicine is the recording and interpretation of narrative.  If there isn’t dictation, and you know how to type, then type as much as possible.  I find that it’s faster to type a story with the salient details than to sort through all of the redundant check boxes.

The reason for this (and I encourage EMR designers to pay attention) is that the history of present illness usually has boxes for associated symptoms, which contains boxes that are virtually identical.  When all is said and done, it can be tough to differentiate between documentation for your physical  and documentation for your history or review of systems.  They all look and sound so much alike, in my experience, you can think you’ve done one, when in fact you’ve done the other. Especially when tired or very busy, “Respiratory:  no dyspnea” sounds a lot like “’Lungs:  no respiratory distress”.  I have found it all too easy to confuse them.

Mind you, the complexities of modern medical billing and core measures require some boxes be checked.  So learn the critical ones, and make sure you hit them.  Things such as the time you saw the patient, or the time you ordered the head CT should always be reported.  And don’t forget the ever-important, “nurses notes reviewed and I agree” box or the fields that show your lab and x-ray interpretations.

And for those very complex cases, use the hospital dictation system or type some additional notes.  By complex I mean resuscitation, trauma, sexual assault, stroke, and other things requiring meticulous attention to detail.

In the end, you have to learn to be flexible and play nice on the EMR. I know, I know.  It’s awful.  It makes us into highly compensated data entry clerks.  And the developers of these “time savers” frequently seem to have no idea at all what physicians and nurses do, nor do they understand the time constraints we face.  But it doesn’t seem to be going away.  However, if you do locums, at least you get to try different systems and leave behind the EMR programs you hate.

So click away brothers and sisters.  Or scribble on your paper charts.  But however you do it, hit the highlights and tell a good story.  And learn to make your chart lean, but full of meaning, for the next doctor who looks it over and for the underpaid person coding it.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test. This article originally appeared in The Barton Blog.

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  • http://www.facebook.com/mtnhawk Seth Collings Hawkins

    Well said Ed! Some things I will add for your readers (partly because I’m also working on a column about this, and have some pet peeves of my own — and hopefully designers and end-users are reading these essays):
    1) If you do choose to dictate (which I agree with you would be the more efficient way to access the EMR), PLEASE be sure to read over what the voice recognition system has generated. I say please not only for the sake of your own pride and charting, but also as someone who loves the English language, and for all your fellow clinicians who may be trying to figure out what the hell you were trying to say days later. EMR errors can be humorous, disastrous, or just plain incomprehensible, but they are never what you want in your chart.
    2) I would politely disagree with you that most EMRs are engineered for billing and data capture rather than clinical care. For billing, I have found time and time again they are poorly configured for billing as well. For instance, you mention “nurses note reviewed and agree” fields. Surprisingly, some systems prebuilt their default to simply say the note is reviewed, without an “I agree” clause, making it the same as no entry at all from a billing perspective. Take some time to determine if the templates and prebuilt options you are activating will actually be functional for your billing system, especially if you self-bill or your billing company doesn’t give you real-time feedback. Assuming that the EMR designer has actually designed the defaults with billing in mind can be a big mistake. For data capture, we have frequently found that the data generated by some of these systems is completely bogus. Again, caveat emptor.
    3) Of course, #2 begs the question: what users or functionality did the designers have in mind when they built most EMRs? I’m still trying to figure that one out… all I can think so far is their benefit as vendors. That being said, clearly this is the way healthcare will be moving, so as you demonstrate via your timely essay, we all need to be vocal participants in that movement.

  • http://www.facebook.com/profile.php?id=1536821513 Edwin Leap

    Thanks for adding your wisdom! I guess it’s more accurate to say that they may be marketed as an adjunct to billing, but don’t necessarily pan out. Fortunately, our EMR and billing company work well together. You’re right. They aren’t going away. But we need to make them as functional and simple as using an i-Pad. Which apparently even cats can do given the right program! Great to see your comment.

    • buzzkillersmith

      I agree that EHRs are not as bad when someone else inputs the data. But it’s tough to get CorpMed or even small groups to pay for that.

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