The hype these days in health information technology is all about electronic medical records. They are being toted as the way to improve patient care and create interoperability through the entire healthcare system. While these goals are truly incredible, the reality of them have yet to surface. Doctors are being nearly forced, by government regulations, to adapt this technology that most find wanting. Doctors feel that the EMR greatly slows down their work flow and cause inefficiencies in the system. And interoperability seems to be far in the future as many simple interfaces between systems fail to be easily accomplished.

EHRs have been the topic of improving patient care and clinical outcomes. While some studies have established this, most doctors are again not seeing this on the frontlines in their clinical practices. In fact, many feel that the EHRs are directly interfering in their ability to adequately take care of their patients.

How Are EHRs Disrupting the Doctor-Patient Relationship?
1. When doctors take their tablets, notebooks or other handhelds into the exam room, they are now concentrating on the patient as well as the EHR. I have heard many patients complain that the doctor no longer pays attention to them but rather spends time just looking into his/her computer.
2. Most doctors feel that data entry into the EHR has proven to be a time drain. Many doctors take this work home with them or do it after hours. This is adding to the stress that most doctors are already feeling. Similarly, the doctors that attempt to do it while seeing the patient or in between patients, often get behind in their schedules. Patients do not like to wait.
3. Every EHR has their own standard of formatting records. There are 100’s of EHRs out there and everyone is different. It becomes extremely difficult sometimes, to find the data in the record that is needed to take care of the patient.
4. Systems occasionally go down. When this happens, so does our ability to access the patient chart or even schedule appointments. The whole workflow of everyone working in the office gets disrupted.
5. With the rise of EHR use, regulations such as Meaningful Use have come into play. While now it is an incentive program, in the future, doctors who do not comply with these regulations will be penalized. Meaningful Use, especially for a small practice, is very time-consuming. And in order to qualify, many more metrics than are needed become required to be reported in the patient chart. The minutia added takes time away from the patient and makes searches of the chart for needed information more difficult to happen.
6. Along with EHR came the electronic prescribing program. While sending e-prescriptions is a great aid, they sometimes don’t go through. Patients are sometimes led to believe that the doctor never sent the prescription because it never arrived at the pharmacy. Call backs from the patient and pharmacist further act to disrupt the doctor-patient relationship.

While electronic records have a great potential for improving outcomes and making us more efficient, the reality has not been achieved yet. The technology needs to be improved and evolved to match what those on the frontlines (ie physicians) need. Systems need to be able to be customized to our workflow rather than trying to get us to adapt to technology we believe is sub-standard.

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One thought on “How Electronic Medical Records Are Disrupting The Doctor-Patient Relationship

  1. I can’t speak to the legal system isuses (if you’re referring to medical malpractice risk avoidance), but I CAN speak to the insurance industry part of your post since E/M coding, auditing and physician education is my thing . I probably taught one of the first classes in E/M coding when the codes first came out in January 1992 and to this day, the majority of the consulting and education work I do surrounds understanding the appropriate use from a clinical perspective these codes. As a result, I can say with a high degree of confidence that if the physician does just 2 simple things, 95% of the time they’ll have absolutely no problems having sufficient documentation to support the appropriate level of E/M service:(1) Practice good medicine(2) Be diligent about documenting what you did during the encounter. If it’s important enough to ask the question or to examine, it’s import to write down the response/finding, regardless of whether it’s a positive or a negative finding/response.There are a handful of codes where the appropriate level of service requires that the physician SOMETIMES do/ask what may not be clinically intuitive for the patient’s presentation. But for those instances, what the doctor needs to remember to do above/beyond what’s clinically intuitive is something that I literally could write for you on the back of a business card. Yes, with a couple of exceptions those are the HIGHEST level of service you could report for that category of code (the exceptions to that in the office setting are level 4 new patient visits and level 5 consults). But for the vast majority of physicians (all specialties) if you look at the acuity and/or clinical complexity of their entire panel of patients, the instances where that highest level of service SHOULD be reported (based on how cognitively difficult the encounter was) is a relatively low portion of all of the physician’s office E/M services.Or let me put it this way I haven’t seen a work up of a problem(s) yet that was truly deserving of being reported as a 99214 service where the physician didn’t AUTOMATICALLY *need* to ask ROS questions in 2 or more systems, or didn’t need to do a detailed physical exam of the affected (and related) body areas/organ systems ( need to here being defined as needed if the doctor was practicing good medicine). No the biggest problem with there being a mismatch between the level of service reported and the volume of documentation in the record are the kinds of problems I’ve listed below.(1) It was a lengthy encounter and one that would have qualified for billing the higher level of service, but the PHYSICIAN FAILED TO DOCUMENT THAT THEY WERE USING THE TIME RULE to select the level of service. Where more than 50% of the face-to-face time is spent in counseling and coordination of care, time should be used to determine the level of service. The physician must document that they spent X minutes of a Y minute face to face encounter discussing .. then include a sufficient SUMMARY of the discussion to justify the amount of time claimed (in other words, would another physician of your specialty have agreed that a discussion of those isuses would have typically taken the amount of time claimed in the record). (2) The level of service selected was clinically appropriate given the cognitive difficult of the assessment, but the physician failed to document the negative exam findings and/or negative ROS responses obtained during the assessment. Had that work been documented, the level of service selected would have been supported by the volume of documentation too. (that where the not documented, not done mantra comes from).(3) When you look at the problem severity description for the E/M level selected, the problem(s) the physician was evaluating were more appropriately represented by the problem severity descriptor for a lower level of service. In other words, irrespective of the volume of documentation, the physician simply overvalued the encounter. So yes, we can talk about those things that aren’t clinically intuitive that you need to get into the record for your MORE COMPLICATED new patient and consult visits. And we can talk about whether (and how often) when 99215 is the right level of service, you’ve got to remember to document things that aren’t clinically intuitive in order to support the 99215. But for the rest of the encounters, I think you’ll find that if you haven’t made one of the 3 mistakes I described above, if you are diligent about documenting only what you actually did (and needed to do) during your assessment of the patient, the right level of service for that visit will be supported.And the best thing about that is that you’ll see that there’s absolutely no clinically superfluous information in those progress notes to essentially sterilize or confuse the clinical picture of what was actually going on with the patient’s health at the time of your assessment.No, the problem comes when you think that documentation drives the level of service. It doesn’t. The Medicare program published that rule way back in 2001 [Pub 100-4, Chapter 12, Section 30.6.1 (A)]. The AMA reminded us of the role of the contributory component the nature of the presenting problem(s) (problem severity) to assist physicians in their selection of an E/M service back in a CPT Assistant article from August 2006. If you can set aside your current perceptions about E/M codes and the documentation requirements and go back to the code definitions themselves looking at the problem severity descriptors ALONG with the requirements for the key components of that code I think you’ll see what I’m talking about. If you understand how the type of workup you need to do (from a clinical perspective) equates to which level of service, you’ll see that the AMA and CMS actually did a pretty good job describing what you need to do clinically along the continuum of cognitive difficulty from the fairly simply presentations to the most complex. Again, if they made me emperor, that’s not to say I wouldn’t change a few things! But the system, as it’s designed right now, usually doesn’t require you to document anything more than you found it medically necessary to do in order to support the level of service that’s consistent with the cognitive work you did. The few instances where extra documentation may be needed (and extra work actually performed), it’s limited to those encounters where the cognitive work you did was represented by a code that requires a complete history and/or a complete exam and what you needed to do clinically was a couple of elements short of that.EHR’s are perpetuating the myth that documentation drives the level of service. In the long run, IMHO, we do our patients (and our physician colleagues) a disservice by buying into the hype.

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