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Readers Write: It’s Time to Get Doctors Out of EHR Data Entry

April 20, 2016 Readers Write 9 Comments

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. 

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Currently there are "9 comments" on this Article:

  1. Seems odd this would come from someone that works at a medical transcription service, first of all. Sounds to me in some respects they are trying to push their business services. I worked on the vendor side of EHR sales for around 8 years. Physicians (not all but a large majority) pushed back from the very first mention of “change”. They didn’t show up for training (often), so they were not “bought in” to this new paradigm shift to EHR. I can recall many saying to me … I’ll quit medicine before you will see me using an EHR. Now I blame that on how all this was positioned and rolled out by the industry. As technology improves and connectivity becomes more of a reality, this will all get better. Look what has happened with the first wave of the Internet compared to today. Related to transcription services a vast majority of physicians have told me there were mistakes quite often in their transcribed reports, they are not back in the patient chart for sometimes 24-72 hours … and in an attempt to cost cut many physicians and practices used off-shore (India based) services, that made all that worse. I don’t disagree with the overriding premise that we have to keep working harder to ultimately improve the provider-patient relationship … which yes of course is impacted when physicians are spending too much time on data entry, but what i am hearing which is important is that the general public perception of an eMedical Record, the ability to communicate via portal or some other means is a big improvement over the past. When I’ve spoken with my former physician clients one year post EHR implementation … most will say there are still challenges and frustration, but if you ask them if they want to go back to paper the answer has been a definitive no. And in closing, I’m not aware of any EHRs out there that cannot be used with Dragon or M*Modal technology … and when used properly will certainly trump the issues already stated around transcription.

  2. You are so right!

    And tell the truth about about voice recognition. I am less productive and much less happy using it. And of course, my income is lower. After the hospital pays me to correct errors, hires more people to do same overall workload and opens itself up to lawsuits because of errors, I cannot believe they really save money.

  3. sad part is, it’s not up the doctors. it’s the administration and they are going for the cheapest possible option, which is always going to be technology over the actual person. If they ever do decide to go back to MTs they will find there are very few left. Large MTSOs have brow beaten and financially ruined all of the good MTs. Greed has destroyed this field.

  4. The title of this article certainly sparked my interest and is somewhat disconcerting. Although I agree that doctors need to spend time with patients we have always, and will continue to need, documentation on that visit. As MC mentioned, most systems can work with Dragon or others allowing their dictation to flow directly to the EHR. Every step and set of hands in between opens the doors for errors (think of the game “telephone”). Also I don’t see how the additional charges for interfaces are warranting of an entire “step” to fix this problem. Because each EHR implementation (and the ancillary applications it works with) is different from site to site, charges for interfaces need to be included so that the scope of the project can properly reflect the amount of work to be done. These fees also represent the work required from the ancillary software vendors that do not get any of big chunk laid out for the entire EHR. I doubt that those nominal fees are preventing any doctor from getting their documentation to flow better.
    We need to remember to document smarter, not less.

  5. The article is accurate and correct that doctors need to stop being secretaries, but an important option for data entry is not mentioned – patient entered data.

    Instant Medical History (IMH) is included as part of most EHRs under various names. It queries the patient for any of thousands of complaints with simple 7th grade level questions replicating as a physician would do. It is a domain expert system, branching as needed. Then IMH transforms the answers into a SOAP note that resembles a physician record. Various levels of EHR integration allow completion of templates or presentation of a dictation-like note pre-populating the electronic record. Decision support features can apply preventive rules and recommend guideline deficiencies to staff. On arrival, the staff does the medicine reconciliation and any preventive items and makes sure the visit note contains IMH data. The physician simply reviews the data with the patient. The EHR is already 70% complete (the subjective is 70% of any medical record). For additions or corrections to the patient entered data, the clinician may dictate these edits for the transcriptionist and adds the assessment and plan. This workflow avoids most of the 54 minutes a day doctors spend dictating without IMH and it creates a much more complete note. Instant Medical History requires simple workflow changes to allow the patient to enter the subjective portion of the visit note at home via the patient portal before the office visit.

    Allen Wenner, M.D.

    Disclaimer: I am VP of Content Design for Primetime Medical Software, Inc.

  6. If doctors are so unhappy with EHR entry, they should be more aware of the fact that the so-called Affordable Care Act (which made healthcare unaffordable) mandated an EHR. In addition to new work for the physician, we now have the government tied into every medical record in the country and with the government’s known propensity to snoop on everyone, confidentiality has basically gone out the window. If doctors want to get free of the EHR and the added duties that go with it, their professional associations should lobby their representatives in the House and Senate to repeal the Affordable Care Act entirely. Also, if they had stood up for their in-house MTs who were dedicated to doing a great job documenting their records for them, they wouldn’t be in this boat now. Instead, they stood by while CFOs and others decimated the in-house medical transcriptionist profession to save a quick buck and look good on paper.

    • Tony,

      Where to start?

      -ACA did not mandate an EHR.
      -There is little to no interaction between the EHRs and the government — the only thing I can think of that you would apparently consider “snooping” would be CDC Case Reporting — which is initiated by the clinician, or at least sent by the EHR
      -The government is NOT tied into every medical record in the country
      -There is absolutely nothing in the EHRs that prevent MTs from working, so if they were that good they would have been integrated. It looks like the MT profession has been replaced by the scribe positions.

      There is a need to reduce the workload, but I don’t see how going back to tape recorders is any better an option than interoperating with a fax machine

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