The EMR has become a focal point in the physician burnout discussion. Although I believe EMRs are a necessary evil, current iterations of them are just not good. Each click on a mouse is a prick on the many good souls that figuratively bleed until they are physically and mentally burned out. Scribes are not a solution either. That is just a workaround. EMRs are one of many things that need to change in our health care system. But I also believe our concept of clinical documentation needs to fundamentally change.
I’d like to present a roadmap for this change. Although it may seem farfetched and perhaps science fiction, we need to start thinking along these lines to move our clinical documentation to a new era where we aren’t slaves to pointing and clicking.
Step 1: We need to move past the E&M coding system and simplify reimbursement
The Center of Medicare and Medicaid Services (CMS), and insurance companies need to find a way to make this a viable option economically for everyone. I completely agree with experts that look at the EMR as a glorified cash register. EMR design and innovation has been limited by billing and coding requirements, which in turn determines reimbursement. A big chunk of our “clicks” in an EMR is dedicated toward how much we put into the review of systems, physical exam, entering codes, and documenting how medically complex the entire visit was. If we make reimbursements for office visits a flat rate, the burden of documentation will decrease significantly. This also creates transparency for patients who are often left befuddled at how much office visits cost.
Step 2: We need to advance clinical documentation from being text-based to multimedia
One of the main purposes of clinical documentation is to create a medico-legal record. We’re always taught, if it’s not documented, it didn’t happen. The clinical “note” is records of what happened. I suggest advancing the idea that if it’s not heard (i.e., audio) it didn’t happen. With technology and our ability to manage data, I can imagine a system where audio of every office visit is recorded and securely stored in the cloud. This creates a word for word audio transcript of each visit. If you want to think more progressively, create a secure video of the visit too. If you want to be patient-centered and ultra-progressive, allow patients to stream the audio and video of their office visit. They can replay office visits in their own home, be more engaged in their health, and perhaps improve their clinical outcomes. Less clicking, more talking and let the digital audio-visual record be the source of truth.
Step 3: Advance the use of voice-controlled technology to get stuff done
I can use my voice to get the news, get the weather, order groceries, and have stuff delivered to my house. This technology needs to come into the clinic and become a fluid mechanism for ordering things.
“Alexa: Order a CMP, lipid profile and urinalysis for Mr. Bezos.”
“OK, Google. Refill a 90-day supply of Mr. Pichai’s hypertension meds.”
“Siri: Refer Mr. Cook to cardiologist Dr. Apple for management of atrial fibrillation. Send copy of last EKG.”
Step 4: Advance the use of natural language processing and artificial intelligence (AI) to create the written visit record
If we have audio/video records of every visit, it will be too time-consuming to watch and listen to prior visits. It’s faster to read a summary of what happened. We need our colleagues in the tech industry to develop natural language processing technology that can convert the audio feed into a succinct progress note. The new progress note will be written up by AI and not by humans.
Step 5: Train a digitally savvy health care workforce that can flourish in this model
A system works only as well as its users. Schools (medical, nursing, NP, PA, and others) need to train the future workforce to become adept with clinical documentation that involves more than just a keyboard and mouse. With our current EMRs, the most basic practical skill we should be teaching in schools is typing; an archaic skill based on the typewriter invented in 1878. It’s a shame that the survival of our health care workforce is dependent on 19th-century technological expertise. As the clinical documentation system evolves (I hope), medical education needs to follow closely and prepare them to flourish and become innovators that continue to drive change.
This entire vision may seem like a pie-in-the-sky fantasy. But we have real problems in health care that need drastic solutions. Physician dissatisfaction and burnout are real. EMRs — despite best intentions — have become an albatross. The financial aspects of our health care system are a complicated mess, and patients have a hard time engaging the system. Our education systems also haven’t figured out a way to best prepare students to handle these issues.
Workarounds and piecemeal fixes will only help to sustain this unsustainable status quo. We need to open our minds and reimagine the very core aspects of how we finance, document, deliver, and teach health care.
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