The Worst Features About EHRs and How to Fix Them

The following is an except from an article Published in “Neurology Today.”  It includes an interview where Michael Stearns, MD provided feedback on challenges related to the use of electronic health records (EHRs).

“THE NOTES READ LIKE JUNK”

“EHRs differ so vastly in how they manage documentation, said neurologist Michael Stearns, MD, CPC, former president and chief executive officer of e-MDs, Inc., an EHR company. “For neurologists, I’ve personally found that focusing on a basic set of templates (for example, a follow-up migraine visit) is a good way to start,” he advised. He believes that computer-assisted documentation works best when at least a significant portion of the visit note can be anticipated in advance, although he stresses that it’s important that any template-generated text be carefully reviewed to make sure it represents what actually occurred during the encounter. “As neurologists deal with extremely complex issues during visits, they need to also have the ability to document outside of templates,” he added. This is particularly true, he explained, when capturing information in the history of present illness, study results, and in the assessment and plan.

Dr. Stearns said voice recognition software is very helpful in neurology, in particular during the early stages of implementation, while the provider is refining templates. “Over time, the voice recognition software may be used less as the provider can incorporate commonly used items such as patient instructions into the preformatted text,” he concluded.”

The article also addresses other troubling EHR features such as:

• “Documentation Take Too Long”
• “It Change My Workflow”
• “It Prevents Eye Contact”

Since the article was published in 2012 the same factors represent primary concerns of physicians.  Since then quality reporting and population management requirements tied to Meaningful Use and accountable care, are additional areas that challenge physicians.  Medicare recently authorized additional reimbursement for patients with two or more chronic illnesses, but this only marginally offsets the demand on physician time to manage avalanches of data.

Article: The Worst Features About EHRs and How to Fix Them

A previous article in Neurology Today that quoted Dr. Stearns on the value of templates in clinical care is available at this location: “Can’t Find the Right EHR – Help is on the Way”

The information in this post, unless otherwise attributed, represents the opinions of Dr. Michael Stearns