There was a day when medical transcription was neat and clean. A doctor dictated what happened during an exam and a transcriptionist accurately typed each detail into the patientâs record. Each future encounter built on that record, a detailed history meant to ensure quality care. It wasnât a perfect system, but it worked.
Now, doctors sit for hours each week in front of a computer screen entering patient encounter data into electronic health records (EHRs). These complex systems were meant to more efficiently and effectively track health data for hospitals, payers, and physicians alike. And EHRs were promised to save physician practices, hospital systems, and other provider organizations millions of dollars in the long run.
Reality shows something quite different. Placing documentation responsibilities on physicians is resulting in severe problems not only for doctors, but for patients and the hospitals/practices who serve them. According to a Northwestern University study, physicians with EHRs in their exam rooms spend one-third of their time looking at computer screens, compared with physicians who use paper charts who only spend about 9% of their time looking at them.[i]
Doctors play an integral part in developing and maintaining medical records. But we are asking them to do too much, and the entire healthcare system is suffering because of it. Instead of dictating information into the medical record, many physicians are required to type notes into their EHR, which is time-consuming and distracting. Thatâs just one challenge they face when required to directly document into an EHR.
Upon accessing the system, the doctor enters a patientâs medical number and their record pops up. There are boxes for history, medications, procedures, etc. This âstructured dataâ methodology allows physicians to click radio buttons or check boxes to denote what was done, but too often allows for little or no free text. Physicians are presented options from which to choose, even if those options arenât applicable. The structured data choices canât be changed, and the patientâs record is built off what the doctor ultimately chooses as the lesser of evils. This type of documentation may work for someone with a specific problem, like bronchitis. But for a complex cancer patient who requires multiple treatment protocols, limited choices will hinder building an accurate picture of their care needs.
Most EHRs allow doctors to copy and paste information from one area of the record to another. This creates ânote bloat,â a serious issue thatâs resulting in junk data and unwieldly, unmanageable records. Itâs not uncommon for information copied from one patientâs record to end up in a different personâs file. Doctors are busy, and when theyâre in a hurry, the default is often to overuse copy/paste functions. Not only does that create note bloat, it causes mistakes.
Those data errors can be costly. One hospital was recently sued by a patient who suffered permanent kidney damage from an antibiotic given for an infection. The patient also had a uric kidney stone, which precludes antibiotic use. The EHR file was so convoluted, none of the attending physicians noticed the kidney stone. Printed out, the patientâs record was 3,000 pages. The presiding judge ruled the record inadmissible, in part because a single intravenous drip was repeated on almost every page.[ii]
The move to pay providers based on the quality of the care they deliver instead of the volume of cases they treat is driving much of the federal healthcare discussion.[iii] And thereâs a chance that work can help restore sanity to the interaction between doctor and document. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the bill that ended the onerous Sustainable Growth Rate, authorized the Centers for Medicare and Medicaid Services to pay physicians via value-based reimbursement for Medicare patients.
The law also instituted a replacement for Meaningful Use. One component of MACRA is the Merit-Based Incentive Payment System (MIPS) that, among other things, incentivizes providers for using EHR technology. The goal is to achieve better clinical outcomes, increase transparency and efficiency, empower consumers to engage in their care, and provide broader data on health systems
This is progress, because at the end of the day, patient focus should always trump data entry by physicians. Thatâs not to say that physicians shouldnât have a hand in documentation. According to Association for Healthcare Documentation Integrity, accurate, high-integrity documentation requires collaboration between physicians and the organizationâs documentation team â highly skilled, analytical specialists who understand the importance of clinical clarity and care coordination. Certified documentation and transcription specialists can ensure accuracy, identify gaps, errors, and inconsistencies that may compromise patient health and compliance goals. AHDIâs recommendation: Include wording that expands the definition of ânon-physician members of the care teamâ to include certified healthcare documentation specialists and certified medical transcriptionists.â[iv]
Accurate, clean patient medical records are a necessity in todayâs value-based healthcare industry. Bad data results in slower or non-reimbursement and increases scrutiny on hospitals, physicians, and other provider organizations. Thereâs not a single documentation and transcription scenario that meets every organizationâs needs. But there is common ground where all stakeholders â EHR vendors, documentation specialists, transcription experts, physicians, hospital administrators â can create a structure that results in clean, effective, understandable patient medical records.
Step #1 â Reduce doctorsâ administrative burdens
Surgeons want to operate. Family practitioners want to diagnose and treat. Specialists want to cure. But documentation demands imposed by strict EHR policies and structured data limit their ability to do what they love. A physicianâs role in documentation should be focused on dictation, not data entry. EHR voice-recognition software allows doctors to directly narrate into the system. Like any other text, narrated notes need to be reviewed for accuracy and then approved. In some cases, doctors are approving their entries without reviewing them. This increases the risk of inaccurate data and mistakes.
Further reading: Physician wellness is a quality metric work measuring
Step #2 â Find a balance between structured and unstructured EHR data
There is a place for both structured and unstructured data in the EHR. CMS requires structured entries for demographics, vital signs, smoking status, problem list, medication list, medication allergies, lab tests/values, and a minimum of one family history entry. But many EHRs require that doctors use structured formats far beyond want CMS demands. One report stated that 91% to 93% of information entered in structured forms could be captured via dictation, transcription, and free-text entry.[v]
Step #3 â Eliminate interface barriers
EHRs require interfaces to âtalkâ with other systems, but the fees charged for interfaces discourage providers from using outside documentation and transcription services. Interfaces are necessary, and should be part of the standard development of EHR structured data forms and information collection.
Step #4 â Put the responsibility of document editing and transcription in expert hands
I believe there will be a resurgence of transcription services in 2016. We are routinely approached by physician groups and hospitals who ask us to edit and transcribe patient encounters that they then upload to their EHRs.
EHRs are here to stay. So are documentation and transcription experts. Provider organizations need both of us. When experts on both sides combine their strengths and expertise, we can put doctors, physicians, and other healthcare professionals back where they belong: taking care of patients.
[i] Enid Montague, Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctorâpatient communication and attention, International Journal of Medical Economics, March 2014, Volume 83, Issue 3, Pages 225â234 http://www.ijmijournal.com/article/S1386-5056(13)00244-X/abstract
[ii] Lucas Mearian, Lawyers smell blood in electronic medical records, Computerworld, April 13, 2015 http://www.computerworld.com/article/2909348/lawyers-smell-blood-in-electronic-medical-records.html
[iii] Meaningful Use Definition & Objectives, Healthit.gov, https://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives
[v] Fred Pennic, Study: Physicians Are Capturing More Structured EHR Data than MU Requires, HITConsultant,net, Oct. 9, 2014 http://hitconsultant.net/2014/10/09/physicians-capturing-more-structured-ehr-data/