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Need Point of Care EMR Documentation to Meet Future EMR Documentation Requirements

Posted on April 12, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As part of my ongoing writing about what people are starting to call the EHR Backlash, I started to think about the shifting tides of EMR documentation. One of the strongest parts of the EHR backlash from doctors surrounds the convoluted documentation that an EMR creates. There is no end to the doctors who are tired of getting a stack of EMR documentation where 2 lines in the middle mean anything to them.

Related to this is the physician backlash to “having to do SOOOO many clicks.” (emphasis theirs) I still love the analogy of EHR clicks compared to playing a piano, but unfortunately EHR vendors haven’t done a good job solving the two things described in that article: fast predictable response and training.

With so many doctors dissatisfied with all the clicking, I predict we’re going to see a shift of documentation requirements that are going to need a full keyboard as many doctors do away with the point and click craziness that makes up many doctors lives. Sure, transcription and voice recognition can play a role for many doctors and scribes or similar documentation methods will have their place, but I don’t see them taking over the documentation. The next generation of doctors type quickly and won’t have any problem typing their notes just like I don’t have any issue typing this blog post.

As I think about the need for the keyboard, it makes me think about the various point of care computing options out there. I really don’t see a virtual keyboard on a tablet ever becoming a regular typing instrument. At CES I saw a projected keyboard screen that was pretty cool, but still had a lot of development to go. This makes sense why the COWs that I saw demoed at HIMSS are so popular and likely will be for a long time to come.

Even if you subscribe to the scribe or other data input method, I still think most of that documentation is going to need to be available at the point of care. I’ve seen first hand the difference of having a full keyboard documentation tool in the room with you versus charting in some other location. There’s just so much efficiency lost when you’re not able to document in the EMR at the point of care.

I expect that as EMR documentation options change, the need to have EMR documentation at the point of care is going to become even more important.

RACs Ordered To Analyze EMR Template Data

Posted on December 26, 2012 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

EMR templates are coming under increasing fire of late, with regulators arguing that they’re not doing a good job of justifying the reimbursement that doctors are requesting. Now, in a move that can only be described as racheting up the pressure, CMS has revised its instructions to Recovery Audit Contractors (and their brethren) to demand that they look more closely at template documentation.

According to a report in EHR Intelligence, CMS has issued new orders asking RACs and other recovery contractors to review templates, extract usable data, and use that to determine whether reimbursement requests are legit. Specifically, it’s asking contractors to focus in on limited space progress note templates and open-ended progress note templates.

CMS isn’t asking providers to stop using templates, but it does seem fairly disapproving, particularly of limited space templates, which it regards as largely inadequate for payment purposes

“Review contractors shall remember that progress notes created with Limited Space Templates in the absence of other acceptable medical record entries do NOT constitute sufficient documentation of a face-to-face visit and medical examination,” the agency says in its contractor instructions.

The agency notes that templates using checkboxes and predefined answers to enter information generally don’t work. “Claim review experience shows that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met,” the instructions note.

Well, there you have it. You’ve got an agency that’s coming down hard on the use of inadequate templates, but “does not endorse or approve any particular templates.”  Seems like a recipe for disaster.

If CMS refuses to propose a specific template design, I say it’s incumbent on the industry to do so. With so much at stake, it’s time to lay out a design that vendors and providers can live with and hand it to CMS.  Maybe that will spur the agency to take a stand.

EMR Templates

Posted on September 6, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’m always fascinated by a discussion of EMR templates. A little while back on the 3M blog, they wrote what I think is a pretty good summary of the pros and cons of EMR templates:

Using template-based documentation provided by most EHR vendors allows for documentation to be available almost immediately for communication with the rest of the care team, which is important especially for daily progress notes. Choosing templates over dictation-transcription eliminates the variable of transcription turnaround time, which can range from a few hours, to a day or more. Templates also allow documentation to be created in a consistent and structured format, with up-to-date problem lists.

There are clearly many benefits associated with the use of templates, however from what we’re hearing there also are a number of drawbacks to this strategy. Coding, communication with other care providers, and physician efficiency can all be impacted by template-based documentation. We’re seeing that physicians don’t capture as much information when they fill out a form-based template as they do when they are allowed to capture the patient narrative in their own words, either through writing or dictating. Key information may be missing, which impacts both the care team and coding—and could result in the dreaded “every patient looks the same from the documentation” issue. Some physicians tell us that templates slow down their daily workflow, making them frustrated with their organization’s EHR implementation.

The discussion of EMR template use is a complex one. In many cases you can see the benefits of using an EMR template, but there are also a lot of downsides to their use. I remember when Dr. West wrote a blog post about why he loves his EMR templates. As I thought about his views I realized what the difference was in his templates and the templates that many other doctors use. He created his own EMR templates that were specific to him. I think that makes all the difference in the world.

Turns out that no one really hates EMR templates or loves EMR templates. They’re just a means to an end. What then are the benefits and challenges of using EMR templates.

EMR Template Benefits:

  • Saves Time (if designed well)
  • Helps Ensure Standard of Care
  • Documentation Always Found in Same Location on the Page

EMR Template Challenges

  • Every Chart Looks the Same
  • Lots of Clicks (if designed poorly)
  • Abnormals are Difficult to Identify
  • Difficult to Document Multiple Chief Complaints
  • Template Not Physician Specific (or takes a lot of time to create ones that are)

I’m sure there are other points worth noting. I look forward to hearing which ones I might have missed in the comments. I think the key when considering templates is how to make sure you get the benefits while mitigating the down sides. I think this is possible, but it takes some time and a thoughtful approach to make it happen.

Common EHR Implementation Issue – Inadequate EHR Templates

Posted on September 6, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Time for the latest entry in my series of Common EHR Implementation Issues. See also my previous posts on Unexpected EHR Expenses, EHR Performance Issues and a little follow up to avoiding the EHR performance issues altogether.

This weeks common EHR implementation issue is: Inadequate EHR Templates.

Before I begin with the major issues of inadequate EHR templates, it’s worth noting that there are a few EHR software out there that use a different EHR documentation paradigm than templates. For example, some use voice recognition to power their documentation. Others have a system that learns your documentation over time and based on that learning remembers how you want to document certain procedures. Others, use lots of independent documentation methods (one EHR vendor calls them controls – check box, radio button, freetext field, etc.) which can be grouped and used in interesting ways.

However, even with all of the above alternative documentation methods, there’s often an element of templating that’s occurring. They’re PR and marketing people will shudder at the term template, but concepts related to templates seem to pretty much always apply. For example, in voice recognition there’s something called a Macro. That’s basically a template. The EHR system that learns your documentation method is just using your initial documentation in the EHR to create personalized templates of how you like to document. The independent documentation methods often group those various “controls” into groups of common visits. That sounds like a template to me.

I’d be interested to hear of an EHR system that doesn’t use the principles of templates. It is worth noting that all EHR templates aren’t created equal. Some are much more flexible than others. Now to some details.

The inadequate EHR templates shows itself in a number of different ways.

No Specialty Specific EHR Templates – This has to be the complaint I hear the most. It usually goes something like this, “The EHR salesperson said they had templates, but they don’t have any templates I can use.” Did someone say EMR salesperson mis-communication? Yep, happens all the time. Let’s be honest for a second. How could the EHR salesperson know how good their cardiology or neurology templates really are? They just go by what they hear and what they’re told by the EHR company.

Incomplete or Unusable EHR Templates – You may have noticed a subtlety in the quote I put above. At the end the doctor says “templates I can use.” Maybe the EHR salesperson isn’t lying to you about them having those cardiology or neurology templates. Maybe they do have a bunch of templates for those specialties (or whatever specialty that interests you). However, just because they have templates for those specialties doesn’t mean that you’re going to want to use any of the templates that they’ve created.

My favorite complaint is when they say that the specialty templates seem to have been created be a general medicine doctor and not an actual specialist from that field. I’ve heard it far too much not to mention it.

The other major problem with this point is the unique documentation preferences of each doctor. Has there ever been any two doctors that document the same way? We could debate the good and bad merits of such documentation, but the point is that each doctor is very different. Some feel the need to over document the encounter. Other doctors want to just document the bare minimum. Plus, some (purposefully or not) do a terrible job documenting the visit. The templates in an EHR could reflect any of these various documentation patterns and depending on your perspective could mean that EHR has inadequate templates for your needs.

Hard to Modify, Add to, or Adjust – While not specifically an inadequate template, this is an important part of templates. Turns out that if a user can easily modify, add to or adjust a template that is inadequate, you’re going to be a lot better off. Some template systems are like pulling teeth to modify. Others are amazing at how you can on the fly modify the template.

One promise I can make you, You WILL want to modify their templates. I can’t say I’ve ever heard of someone using the templates perfectly out of the box. Well, maybe I’ve heard of one or two using them, but that was when they were complaining that they had no way to modify the things they wanted to change.

Avoiding EHR Template Inadequacies

The best way to avoid this issue is to test drive the EHR software and the specialty specific templates you hope to use. Run through the templates like you’re charting on some common patients. You’ll learn a lot about what templates are available doing this than anything else. You’ll see if the templates are overkill or below standard for your needs.

Another great test is to try using multiple templates for a complex patient. How easily is that done and how well does the documentation display?

Then, during your EHR demo with the EHR salesperson, ask them to modify part of the EHR template they’re using to document. Tell them you don’t like to ask one of those questions, so you’d like to see them remove it from the template. Many are likely to respond, “It can be done, but I’d have to switch systems to do it or I’d have to call in to tech support to make the change.” I think we all know the real message they’re sending.

For those not interested in EHR templates, you might take a second to read Dr. West’s Experience implementing EHR templates in his office.

EMR Salesperson Myth – Specialty Templates

Posted on May 11, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Time to call out another myth that EMR salespeople love to use to sell their EMR system. Here’s the question and answer that will be familiar to many:

Doctor: Do you have templates for my specialty?
EMR Salesperson: Of course, we have tons of templates for your specialty.

Available templates is one of those myths that is perpetuated by many EMR companies. The problem with the question being asked is that “EMR salespeople” wouldn’t know the difference between a good and bad EMR template if they tried. Add in the idea of specialty specific templates and it’s no wonder they don’t know how to give a doctor a real answer to that question. They are also so far removed from the EMR template development that they can’t reasonably answer that question. So, stop asking the salesperson.

Instead, ask to see all of the specialty specific templates. At least then you’ll know up front the quality (or lack therof) of the EMR templates offered for your specialty.

I’d personally even take it one step further. Ask the EMR vendor to make a change to one of the templates you like. The harsh reality of templates is that almost every (and possibly EVERY) template you get from an EMR vendor is going to need at least some modification to make it look the way you want it to look. You might want to reorder the data, brand the note, add in missing options in drop down lists, or some other edit. Regardless of how big or small, you’re going to be editing the templates you’re given. Better to know up front the process for editing the template. If the person showing you the template baulks at your request to modify the template, that’s a really bad sign.

I’m not hammering on templates either. They can be very effective if created correctly. Just don’t expect a set of practice changing templates right out of the box.