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EMR Documentation by Exception or Veracity

Posted on February 8, 2010 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.

If you’ve been reading me for a while, you know that I have a few hundred draft posts (basically ideas) for future posts. However, the news about meaningful use is coming out so quickly that it’s not that often that I have to go back and use those draft posts. I probably should do it more. Well, when I was working on my soon to be released e-Book on EMR selection, I ran across this comment about two different ways of documenting in an EMR. It’s written by Matt Chase from Medtuity and likely was originally posted on EMRUpdate (sadly, I don’t have the original link).

I’m a total Matt Chase fan boy, and this type of information is what makes him so good. Plus, if you’ve ever received a 10 page note with about 1 small paragraph or relevant information, then you’ll find this information VERY interesting.

There are two methods of documenting with templates: documentation by exception, or DBE, where the template is pre-answered, and documenation by veracity (where you actually gather a history and examine the pt before documenting).

The first (documentation by exception) usually puts into the chart a huge number of normal items and the physician’s duty is to change what does not apply. The “change what does not apply” becomes too burdensome because there is so much fluff on each patient, that it is simply easier to forego the editing. This contributes to the not so unusual findings of “normal clinical *** exam” in a 7 year old boy and “normal descended testes bilaterally” in a 12 yr old girl. Think of it as every 80-yr old male appears on paper identical to every 20 yr old, strapping young man– no abnormalities.

The VA is probably using documentation by exception. The easy way to tell if a system uses DOE is by simply printing an encounter. If it exceeds 1-2 pages, it’s probably DOE.

In contrast, the better method of documenting is for the EMR to present a template with all of the relevant findings, both normal and abnormal but allow the physician to click the findings. For example, a sore throat encounter would have all those things important to a sore throat, including history of fever, difficulty swallowing……through a good neck and throat exam. You would not expect it to document a *** exam, digital rectal exam, or exam of the genetalia. IT’S A SORE THROAT! The documentation would be relevant and short.

With the proper mix of “input controls”, such as checkboxes, right-left-bilateral, positive/negative, multiple choice text controls, calendars, number control, and dozens of other types, it is possible to rapidly enter truthful information. Many EMR’s have only several types of controls (either checked or unchecked), making it easier for the designer of the system to simply put in paragraphs of text (hence the DBE).

Obviously, my disdain for padding the chart with meaningless information is a strong indicator that at Medtuity, we provide a system where the physician clicks to enter truthful information. We take the step of allowing information to be entered quickly.

The local hospital’s emergency department uses one of the “big boy” EMRs that performs documentation by exception. For example, every ankle sprain has a full neurological exam placed in the chart, by default. It does not matter that few ankle sprains receive a full neuro exam. For EMRs designed for DOE, they usually generates a high billing code because including 30 normal findins in the chart is easier than documenting a couple of abnormals.

Selling our product locally always generates the same question: “My documentation won’t look like the ER’s, will it?”. Nobody wants a multi-page report of meaningless normal findings.

One reason, I believe, that there is a lower penetration of EMRs among specialists is this problem of padding a chart with a single click. The charts produced by specialists are actually read by the referring primary care physician. When anticipating a colleague reading the chart, they may hold themselves to a higher standard.

On the other hand, we feel that the scores of questions that are asked by the specialists again and again, with every patient, should be easily responded to with just a few clicks to set many responses to negative. For example, a *** surgeon will ask about *** self-exam findings including lumps, nipple discharge, skin dimpling…through weight loss, bone pain, etc, etc, many times a day. Most of these are negative.

Our profession may blame the insurers and Federal Govt for documentation by exception, but the reality is, it is a design defect. It is very easy to design an EMR for DOE. It is much harder to design an EMR that allows pertinent positives and negatives to be quickly entered.

Probably the easiest method for determining whether an EMR depends on DBE is to ask how many control types they have for entering data. We have over 40 in MedtuityEMR, and counting. I simply cannot fathom how EMRs can get along with just a couple, IMHO.

I asked for a demo of a common peds and family practice complaint (otitis) from “big boy” EMR user. Perhaps this problem has been remedied, but for such a common complaint, there was no means in his template to show:
ear canal occluded with cerumen
bulging TM
erythematous TM
tympannostomy tube present
perforation of TM
location of perforation
retraction of TM
normal TM
scarring of TM
TM motion on pneumotoscopy
………and about 10 other findings that you may wish to show, whether positive or negative) on your ear exam. He couldn’t even click right or left but had to rely on “the affected side”.

There was but one selection available for ear exam (normal/abnormal). That was perhaps two years ago and things may have changed.

So if you are shopping for an EMR and this matters, just ask the demo’er to show you a bunch of abnormal tympannic findings for a screaming 4 yr old. That will tell lots.

Matt Chase
www.medtuity.com
“Practice medicine, not paperwork” ™

Patient’s Demanding Interoperable EHR

Posted on June 2, 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.

A few years ago there was this really funny thread over on the EMR Update forum that asked if doctors would one day display a sign that said “Got EMR?” (this was before the term EHR became in vogue) The concept was asking the question about whether patients would ever demand that their doctor us an EMR or they’d go to another doctor for care. The comparison was made to online banking. I remember online banking being on my list of requirements for a bank. Why couldn’t EMR be on your list of requirements for a doctor?

However, I don’t think most patients really know enough about EMR to want their doctor to ask for it. Maybe if EMR companies and independent studies of EMR really showed a stark improvement in patient care by those using an EMR this would change. Until then, don’t expect patients to start requesting doctors that use an EMR.

With that said, patients may start demanding other things which would tangentially require a doctor to use an EMR. For example, a patient may want their doctor to be interoperable. Patients may want to be able to easily schedule an appointment with their doctor online. Patients may want to start getting script refills done online. Of course, we could talk for hours about patients eventually wanting to actually have the patient visits done online, but we won’t start down that path in this post.

Each of the above patient requirements really needs to have an EMR. We’re definitely not at the point now that patients are demanding these types of features. I wonder if we’ll ever reach this point or if there are just so many patients and so few doctors that even if the patients start asking for these features doctors can continue to do business as usual.

EMRUpdate Videos from HIMSS

Posted on April 6, 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.

Nick Harrington, EMRUpdate guru, is traveling around HIMSS recording some video presentations for those who couldn’t make it to the show. You can find his EMRUpdate videos on Vimeo.

So far he’s mostly posted some hardware related videos, but today he’ll be doing videos of NextGen, UserCentric and tomorrow eCW, e-MDs and SRSSoft. Plus, I’m sure he’ll catch a number of other ones just walking around. I’ll post some of the better ones I see.

Here’s one that I think is interesting since this is something we’ve looked at before. Basically, it’s a video showing the features of a computer cart. We’ve gone back and forth on these. Some people love them and some people hate them. We ended up just thinking they were too expensive. Take a look and see for yourself.

Check out other EMR technology products. I think I need to add a few computer carts to the list.

CCHIT Does Not Measure Usability, Implementation Service, Product Maintenance, Technical and Application Support

Posted on March 6, 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.

A very passionate poster on EMRUpdate recently found something anyone familiar with CCHIT already knew. It’s just really interesting that CCHIT seems to have put this in writing for all to read. Unfortunately, far too many doctors haven’t read this very important information. I’ll do my part and share it here:

“CCHIT, in fact, recognizes some of its own limitations. Its Certification Handbook states: Our criteria at this point can only represent broad, basic capabilities, and . . . these may prove insufficient for some practice specialties, or may be inappropriate or excessive for others; . . . our criteria do not assess product usability, implementation service, product maintenance, technical and application support; and other facts.”
Source: Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems, Harvard Journal of Law & Technology 2008 vol. 22, No. 1, by Hoffman and Podgurski, p. 133-4:

EMR/EHR Selection and Implementation Guide Plans

Posted on March 4, 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.

The more I read comments on this blog and on EMR forums, I realize that there’s a real need for some sort of simple but effective guide to understanding the EMR selection and implementation process. Basically, I’m talking about a mix of showing a realistic picture of selecting an implementing an EMR. A discussion of the realities faced by almost everyone implementing an EMR. This of course would be coupled with some strategies to avoid as many problems as possible. However, hopefully it would also help doctors have a better vision of what they can expect in the EMR selection and implementation process.

DrQ from EMRUpdate was one of my motivations for wanting to do this, so I feel I should give him some credit.

So, this weekend I’m going to start the process of creating a guide for just this. It may end up being a couple guides. Possibly one for EMR selection and one for EMR implementation. It won’t be comprehensive (that’s impossible). It will hopefully provide some value to those interested in entering the EMR selection and implementation process. Yes, process is the right word.

We’ll see how it all comes together. Don’t expect anything earth shattering if you’re well informed about the process already. I’m sure I’ll pull a fair amount of material from what I’ve posted previously on this blog and in articles I’ve written around the web. I also be tapping readers of this website and other EMR forums I participate in the process of creating these guides. My strongest trait isn’t that I know everything about the process, but I feel like I’m surrounded with an amazing online community of EMR users.

I’m still a little undecided on whether I’ll charge for it or not. I guess we’ll see how it all comes together and then decide. Regardless, I want to make sure that whatever money or even time is spent reading the guide returns a value to the reader.

Ok, so thanks for letting me think out loud on my blog. I certainly want to welcome everyone in on the process. Let’s start by hearing 5 lessons learned during your EMR selection and/or implementation process.

IM (Instant Messaging) EMR/EHR Integration

Posted on February 2, 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.

In my first post on IM in a clinical environment I discussed some of the benefits and options available by having an IM program rolled out in a doctor’s office. IM really is a killer application that can facilitate communication. We all know the benefits good communication can bring to a doctor’s office and the pains bad communication can cause.

I love the idea of IM being integrated into an EMR. In fact, so much so that I asked my vendor if they were going to integrate IM into their EMR when they told me that they were looking to integrate the whole Outlook like messaging and calendaring system into the EMR. The response to my IM question was that it wasn’t on their roadmap and that they weren’t sure they’d want an IM popping up while they were in the middle of a patient visit.

I haven’t thought through all the complexities of integrating IM into an EMR in a way that wouldn’t be obtrusive, but would still facilitate the needed communication. However, I’m confident that with a little thought it could be built so that the communication happens without leaving the doctor in an awkward position and while still protecting the privacy of the patient.

Matt Chase, of Medtuity (one of the more forward thinking EMR companies out there), offered some interesting insights into possible benefits of having IM integrated into an EMR. Here’s a quick summary of some of his thoughts on it with some of my own additions.

IM Direct Link to Patient Chart – If I’m sending a message about a patient to the doctor, then it’s very likely that the doctor will want to look at the patient chart.  Certainly I could send the number or possibly the name, but if the IM is integrated into the EMR, then I could include a link in the IM which would take me directly to the patient chart.  As I’m typing this, why not have the ability to embed a part of the patient’s chart right in the EMR?  You could even direct link to a specific part of the chart or document that was uploaded that the doctor might need to see.

Patients Image Shown in Discussion – Assuming you’ve captured the patients image in your EMR for reference (and many do this), why not show the patient’s image in the IM message when someone mentions the patient.  How much would having the picture of the patient help if you received an IM message that said, “John Doe from last week has an abnormal lab.”  Most doctors are much better with faces than they are with names.  In the name of HIPAA, they probably should be.  Why not jog their memory of the patient by including a picture?

Click To Save to Patient’s Chart – Some IM discussions might be worth saving in a patient’s chart.  Sure copy and paste works from other IM programs, but why not make it one click to save it to the patient chart.  Of course, I suggest making it a one click add, but still let it be editable so that someone can format the IM before saving it completely.

EMR Access = IM Access – No one needs to know where you’re signed into EMR.  As long as you’re accessing EMR, then you’ll get your message.  This could be in a room, in your office, on your cell phone at the hospital, or in the Bahama’s when you were checking your EMR because you missed it so much (hopefully not likely).

EMR Defined Groups – Built intelligently, the EMR could be built to know which staff was on duty.  For example, we have a number of lab techs in our clinic.  Either a flag in the EMR or just by the lab tech’s activity in EMR it could know who to send a lab message to.  Look at it like a virtual IM account that the EMR intelligently knows who is available.

I’m sure there are many more features or benefits that would be only available by having IM integrated with EMR.  Are there any others that I missed?  Are there people using IM in their practice?  Is it integrated with your EMR?  I’d love to hear people’s thoughts and experiences with IM in health care.

IM (Instant Messaging) and EMR/EHR

Posted on February 1, 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.

I’ve been participating in a really interesting discussion going on over on EMRUpdate. The discussion revolves around the integration of IM into an EMR or EHR and the role of IM in a clinical environment.

One person suggested the use of a LAN only IM that he’s been using for a while. Looks like a pretty cool software and prevents your users from chatting it up with their best friend across town all day on work time.

My biggest problem with the LAN only IM software is that it’s just one more program that you have to manage. This is why in our clinic we’ve been using MSN Messenger. This comes installed by default on Windows and so it seemed like a logical choice. It also had some good upload features that allowed us to add our long list of users to a new person with little hassle. We have upgraded most of our computers to the latest MSN Messenger, but now it will just manage itself.

The other advantage of the commercial messengers is their advanced chatting and status features. You can add users to an existing discussion or start a discussion with a large group. The status of your messenger automatically updates as you’re away from your computer. I also loved messenger for when I was at home helping my wife who was sick. Just by going to their messenger, everyone in the clinic could see my status that I was at home taking care of my sick wife.

There are a whole host of other features that make the commercial version nice. One simple example is that it tells you when the person you’ve sent an IM to is typing or not. That way you can have at least some idea of whether you’re going to get a reply soon or not.

We only use IM in our individual offices, but I’ve heard of one person that has an IM user called “Room 1” that is signed into Room 1. That way when he’s in the room, he can IM from that room without a problem. Of course, if you’re carrying a laptop around this isn’t a problem. Also, I haven’t tested this yet, but the next version of MSN Messenger seems like it has the ability to be signed into 2 locations. Could be pretty cool.

Of course, I’m sure that everyone’s wondering about HIPAA. In our clinic we’ve decided to just not put information protected by HIPAA in IM. We might say, Dr. Smith Pt 12345’s labs are available now. This makes it so IM doesn’t have to follow the security guidelines required by HIPAA. Some might argue that this isn’t failsafe. I’d respond that of course it’s not, but neither is someone sending an email with the same information. Neither is someone doing any countless number of things electronically. Therefore I treat it similar to how we treat email.

Despite the benefits we’ve seen from using IM in our clinic. It is really interesting to imagine what an IM program integrated with your EMR would look like. What new possibilities would it open up to you? Tomorrow I’ll discuss some of the cool integrations that could be created by a forward looking EMR company that integrates IM into their EMR.