By Gilly Munavalli, MD, MHS, April 02, 2012
Electronic health records (EHR) are a great Trojan horse for many of us. This gleaming trophy promises to aid us in achieving the pinnacle of office efficiency and government compliance. We willingly bring it into our offices, eager to harness its raw technological power to make short work of our seemingly never-ending task to document, document, document. But the trap door in the underbelly conceals an invading force of cryptic templates, diagrams, formatting, permissions, and even technical support. Soon the very productivity we sought to optimize can become shrouded in uncertainty and inaccuracy.
The truth of the matter is that the advent of EHRs has, for better or worse, been thrust upon us, in the form of a government mandate designed to standardize the process of capturing patient encounter data in our office. Whether this is some conspiracy designed to analyze our practice habits, judge our medical proficiency/efficiency, or just give us gray hair, our fate has been set before us. We must learn to co-exist with the beast, tame it, and teach it to serve our needs. Although we can all agree conceptually that EHR may be a good idea, when the rubber hits the road and we are trying to deliver patient care at the bedside, how does this really fit in without slowing us to a snail’s pace?[pagebreak]
Once the software is in place, attention turns to figuring out the best way to capture everything that happens in a patient encounter. It is very difficult, if not impossible, to document the array of complaints seemingly universally prefaced by “As long as you are here.”
Resist the temptation to do it yourself. Your staff can help, as long as you know the rules. Most of us have someone in the room at all times during a patient encounter; we might as well utilize them to convert the patient’s words into electronic format. We must first teach and then properly utilize our trained staff to do the yeoman’s work of data capture, which will allow us to face our patients sans electronic barriers.
Again, though, we must be aware of the rules. In the conventional, paper world, there are guidelines as to who can record certain aspects of the patient encounter, and these guidelines extend to the electronic arena as well. Many Medicare carriers and some other insurers virtually mandate that the history of present illness be captured by the physician or non-physician provider (NPP) directly, and not via the use of a medical assistant or other ancillary staff. From my perspective, it really shouldn’t matter who captures the data, as long as it is reviewed and verified in the presence of the patient and interpretations and conclusions drawn (from this data) are done by the physician or NPP. But be aware that your EHR will indicate who was logged in and entering data, leaving a clear trail any auditor could follow if you are suspected of circumventing the rules.
Using a scribe
A scribe is an individual who is present during the physician’s performance of a clinical service and documents (on behalf of the physician) everything said during the course of the service. A scribe must not be seeing the patient in any clinical capacity or interject his or her own observations or impressions. I was taught to use scribes to document my spoken words on paper while in the patient rooms. This allowed me to focus my attention into eye-to eye, face-to-face contact with the patient, while seated. Studies have shown this seems to lengthen the perceived appointment time in the patient’s eyes, reinforcing the fact that you are indeed listening to their concerns. In a heavy-traffic, high-volume specialty such as dermatology, this can make the difference between a return visit and losing a patient.
In our office, EHR has not changed this scribing strategy. Our providers endeavor to “prescribe to scribe.” All EHR software packages are required to have authentication at the user level, and to provide a background electronic audit trail. Medical assistants can log in and capture most of the standard pertinent review of systems and history of present illness, as an enumerated list, within predesigned templated forms. These forms may or may not be provided by EHR companies and even with existing forms, it can take an inordinately large amount of time and resources to customize templates to one’s individual workflow. This can be a great source of frustration and cost for physicians and their staff (in terms of their time), as they seek to electronically recreate their paper environment. Thankfully, the bulk of template design is a one-time deal, with tweaking taking far less time to perform.[pagebreak]
Conversely, patient portals can lessen the workload and are becoming more mainstream and “must-have” features in EHR packages. These portals can be integrated into practice websites easily and drive a steady flow of traffic to those sites. Patients log on securely from a browser in the comfort of their own home and complete/update review of systems, medications lists, and even brief, informal HPI via pre-designed online forms. Portions of this information are automatically imported into the patient’s notes (the physician must attest to having reviewed them) for the day of the encounter. Some (such as medications) must be manually verified and matched to a standardized list before being accepted as part of the medical record.
While it is easy to hand off paper charts between assistants and physicians for completion, electronic charts are not so easily transferred. Two individuals with different logins cannot typically write into the same patient chart simultaneously due to back-end database limitations. In our office, assistants have certain pre-assigned user rights, which only allow them to record up through the HPI. The physical exam and the assessment/plan are only editable by the physician. The workflow is designed such that as the physician prepares to enter a room and selects that specific patient chart for review, the assistant is automatically kicked out of the chart. Alerts are present to keep untimely log-offs from occurring, but essentially all that is recorded is constantly being saved. This also has advantages, for example, in the event that wireless connections fail.
EHR packages that support different hardware platforms for data entry really can shine here. For instance, the assistant can utilize a swivel-screen laptop to tap/type their portion of the exam, containing most of the prose, whereas the physician can utilize an iPad to tap out the more predictable physical findings and diagnosis. The chart is only complete when the physician closes the note with an electronic signature. Assistants do not have the ability to electronically sign a note, although there are fields designated to allow them to identify themselves as the scribe. Assistants also do not have the ability under their own login to assign codes and perform billing. These services are performed by the physician and may be automatically suggested (with override capability) by the software itself, based on completed bulleted items. Billing is not transmitted and posted until the chart is electronically signed. This may involve a review by a billing specialist prior to posting.
In summary, recognize EHR for what it isa tool and a means to an end. It is still very important to tailor your workflow to optimize your contact time with the patient. This can best be accomplished by hiring, training, and utilizing technology-proficient assistants at the point of care.