It’s Time to Get Doctors Out of EHR Data Entry
By Marilyn Trapani
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 patient’s record. Each future encounter built on that record, a detailed history meant to ensure quality care. It wasn’t 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. 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 and practices who serve them. Doctors are spending more time – in some cases, 43 percent of their day – entering data into EHRs, which means less time available for patients. This continual influx of data is bloating EHRs with unnecessary, repetitive, unintelligible information.
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.
That’s just one challenge they face when required to directly document into an EHR. Upon accessing the system, the doctor enters a patient’s medical number and their record pops up. There are boxes for history, medications, procedures, etc. This “structured data” 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 aren’t applicable. The structured data choices can’t be changed, and the patient’s record is built off what the doctor ultimately chooses as the lesser of evils.
Most EHRs allow doctors to copy and paste information from one area of the record to another. This creates “note bloat,” a serious issue that’s resulting in junk data and unwieldy, unmanageable records. It’s not uncommon for information copied from one patient’s record to end up in a different person’s file.
Not only does that create note bloat, it also causes mistakes. 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 patient’s 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.
In late January, Jay Vance, president of the Association for Healthcare Documentation Integrity (AHDI), testified to the US Senate Health, Education, Labor and Pensions Committee that EHR documentation burdens on physicians can be reduced by expanding language to a draft bill aimed at improving the functionality and interoperability of EHR systems.
The move to pay providers based on the quality of the care they deliver instead of the volume of cases seen by physicians and specialists is driving much of the federal healthcare discussion. There’s 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 to pay physicians via value-based reimbursement. The law also called for 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. But there is more that can be done.
This is progress, because at the end of the day, patient focus should always trump data entry by physicians. That’s not to say that physicians shouldn’t have a hand in documentation. According to AHDI, accurate, high-integrity documentation requires collaboration between physicians and the organization’s documentation team – 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.
AHDI’s recommendation: include wording that expands the definition of “non-physician members of the care team” to include certified healthcare documentation specialists and certified medical transcriptionists.”
There’s not a single documentation and transcription scenario to meet every organization’s needs. But there is common ground to be found where all functions – EHR vendors, documentation specialists, transcription experts, physicians, hospital administrators – can create a structure that results in clean, effective, understandable patient medical records.
Step 1 – reduce doctors’ administrative burdens. A physician’s 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.
Step 2 – find the balance of structured and unstructured EHR data. There is a place for both structured and unstructured data in the EHR. Structured data can be queried and reported on with much greater ease than free flow text. However, doctors complain there aren’t enough options to share narratives about encounters and what patients had to say about their visit. The goal of an EHR is to provide a complete and accurate view of patients’ conditions, treatments, and outcomes. It makes sense to use structured data for entries such as those required by CMS. Using dictation and expert transcription assistance, unstructured free-text narratives and information also can be a part of the EHR while maintaining accuracy and completeness.
Step 3 — eliminate interface barriers. EHRs require interfaces to “talk” with other systems. Fees charged for said interfaces prevent providers from using outside documentation and transcription services. Interfaces are necessary, but should be part of the standard development of EHR structured data forms and information collection.
Step 4 – put the responsibility of document editing and transcription in expert hands. I believe there will be resurgence of transcription services in 2016. Streamlining data entry into an EHR will never replace the need for documentation and transcription experts. Providers will continue to need outside assistance in ensuring patient data is accurately and cleanly logged in the EHR.
EHRs are here to stay. So are documentation and transcription experts. Provider organizations need both of us. When experts on both sides to combine their strengths and expertise, we can put doctors, physicians, and other health care professionals back where they belong: taking care of patients.
Marilyn Trapani is president and CEO of Silent Type of Englewood, NJ.