The sharing of information is one of the most important actions facilitated within the medical field. Electronic Health Records (EHR) were designed to make the task of sharing and receiving patient information more efficient. The Health Information Technology of Economic and Clinical Health Act (HITECH), was created in 2009 to implement EHR and other innovative technologies into medical facilities. EHR allows clinical data to be immediately available to those authorized and eliminates the use of paper, which can easily be lost or misplaced. EHR also allows the tracking of diseases, and the analysis of patient care within a more universal context. EHR technology is still being integrated into many smaller medical facilities, but it will be omnipresent in the future. Of course, with any new technology, EHR has its own set of challenges. The Office of Inspector General (OIG) stated that, “Health IT, including Electronic Health Records, offers opportunities for improved patient care, more efficient practice management, and improved overall public health. However, the Department of Health and Human Services continues to face a number of significant challenges in this information-rich environment.”
Medical records that accurately reflect a patient’s history are a necessity in the value-based world of modern healthcare. When there are too many discrepancies in the EHR records, it may result in slower reimbursement, or a lack of reimbursement all together, and physicians may be put under increased scrutiny when it comes to payments and clinical documentation. While medical records may never be perfect, the goal is to have all parties involved in the record, from physicians, administrators, transcriptionists, auditors, coders, and EHR merchants, to all have a common and thorough understanding of EHR structure. The EHR needs to be as clean, and effective as possible to make this understandable to anyone who has to look at the record.
CMS, Centers for Medicare and Medicaid Services, require a structured way to enter patient demographics, vital signs, smoking status, problem list, medication list, labs and/or test results, and a minimum of one history entry. Many EHR systems can even require physicians to enter in much more information than what CMS requires. Some research suggests that most of the information entered into an EHR could be captured in the dictation done by the attending physician. Cloning, or cutting and pasting from a previous medical record into the current visit note is a big problem when it comes to EHR Systems. The medical document must show the differences in each visit, and show how the needs of the patient were addressed. When the patient’s information is cloned, it compromises the quality and integrity of the note. Features such as auto-fill and auto-prompt can help improve physician dictation and the time it takes, but can be easily abused. The date on the EHR visit cannot be changed without showing what happened individually for each visit, and any changes or improvements. The signature of the provider also must be on every note with the date and time, even when making change such as an addendum.
Physicians are starting to feel the pressure of working with these EHR systems. Per a report from Becker’s Health IT and CIO Review, John Rogers, MD had this to say about his EHR use, “Too often I pull up a record, either in peer review or another setting, and it’s almost impossible to really get an understanding of the story line. On a daily basis I can’t find the information, particularly nurses’ notes and things like that that are really valuable to me. In a sense it’s turned us into data entry clerks. Communication with patients is not only suffering, but communication with nursing and others, as well. It breaks down, we all communicate now just by what goes into that electronic record.”
The AMA reports that in a survey of 940 physicians, 72% said that EHRs made it difficult or very difficult to minimize their workload. This could be because EHR only allows for a fragment of each patient’s story to be told – while keeping the information delivery uniform and minimalist. More time is spent populating and interpreting these records, which means that physicians are spending less time communicating with patients.
This brings to mind a simple question – have EHRs become the emojis and text messages of healthcare? Limiting communication with a few pre-determined characters that must be prescribed to an entire lexicon? The strict, often automated methods of entering information into EHR can take away value physician face time with patients, which can lead to burn out in practitioners.
While EHR are here to stay, there are more ways to work together in medical offices and facilities that will ease the burden for physician and allow them to have more time with their patients. Working with transcriptionists, scribes, auditors, medical coders, and EHR IT experts – are all ways to overcome the challenges presented, especially with education provided on all sides. It’s not enough to simply employ these EHR team members. Education, communication, and integration must all become routine practices. This will help the industry maintain focus on the health and treatment of patients, as patient care should always be the top priority of any healthcare provider.