In a recent Medscape Family Medicine article by Brandon Cohen, “Making EHRs Less Intrusive and Annoying for Patients,” Cohen points out an all too obvious fact, that some physicians see electronic health records (EHRs) as “a giant headache” and “a barrier to good relationships with patients.” Cohen adds, however, that other providers see the EHR as a valuable tool that helps with “efficiency and accuracy” and doesn’t have to impede the doctor/patient relationship. Some of the comments shared by frustrated physician EHR users may be echoed in your office:

• "EHR has turned us from MDs into data entry clerks! We have gone from being a medical practice to an IT firm." 
  
• "I feel less satisfied at the end of the day now. When patients are all gone, I'm typing, spell-checking, and doing autocorrections." 
• "The measures of quality [in EHR] are based on checked boxes, not real outcomes. They have to be, or it fails. Simple is always better!"
• "The most important keystroke is to push the PC aside and face the patient directly."
• "I live in a town that has passed legislation criminalizing texting and driving. A driver is more impaired and distracted when texting than when intoxicated. EHRs and the practice of medicine should be no different. Do you really believe that your physician is actually concentrating on the patient in front of them while their attention is primarily focused on entering data in a computer?"
• "It's time to tell the practice managers, insurance companies, and efficiency consultants that patients expect and deserve a real physician who is a caring human being and is able to take the time and provide the human element that is a major dimension of healing."

These sentiments of frustration are obviously felt nationwide, but what makes the difference for those physicians who appreciate having an EHR? Is it a different generation of users or a different specialty? Could it be the difference in the EHR system or the workflow set up? It may be that all of these factors affect attitudes, but Cohen shares some suggestions from other physicians for making EHR more patient friendly, and, to that end, more tolerable. 

Improving the EHR Experience
Doctors who have found satisfaction with their EHR product offered suggestions to their frustrated colleagues for making the EHR less intrusive. 

Let the patient interact with the computer, too. "[Older] patients feel much more comfortable with the computer when I pull up their actual scans on the monitor and use them to explain their disease...For many patients, the computer is not only an accepted but welcome presence." (Oncology)

Identify the benefits of using an EHR and what works well. "I have a lot of stuff in the current note that used to be buried in the chart (or omitted). Every patient gets a printout of today's interim history and the proposed plan, as well as a list of meds and diagnoses." (Psychiatry)Bigger might be better. "I have a 32-inch monitor screen on the wall and wireless keyboard and mouse. It sucks the patient into their record and is unmatched for patient education." (Primary Care)

Switch the workflow and take notes. "I leave the computer out of the exam room and take notes as necessary, then complete the EHR after the interview, while my assistant is performing her tasks with the patient." (Gastroenterology)

Enter what’s necessary first, then use pen and paper.  "I inform the new patient, 'I'm just going to get some background information, and then I will talk to you about why you are here.' Once the database is completed, I print off the sheets and conduct the history and physical in the same manner I have done for the past 38 years." (Internal Medicine)

Learn to touch-type. "I touch-type, which I highly recommend learning. I can maintain eye contact while entering their history." (Internal Medicine)

Cohen noted that most physicians are not completely satisfied with current EHR technology, but many users are hopeful about what the future will bring to healthcare technology, especially as improvements are made to free up the physician to interact with patients.  
Of course, as one physician pointed out, there is one generation of patients that probably aren’t bothered at all by the presence of the computer:
"They [teenagers] won't notice you looking at a screen because their peripheral vision isn't that good, and they never break their texting trance. ...This EHR [problem] may be a transient issue; it certainly doesn't bother the younger generation."
Perhaps the issue is transient, as the provider above suggests, especially as computers and other technologies saturate our society and lives, but insights from successful users may be beneficial as we transition to this new way of medical record keeping and documentation.  

Ever feel like the government is one big bully, forcing you to  click a box or else? If so, you aren’t alone. At a recent conference presentation I attended on EHR use, the presenter* revealed that a good portion of the providers at his practice feel bullied into using an EHR. Their comments included

•  “I don’t really care what the government wants me to do.”
• “I want to tell my story in my own way, in my own words.”
• “An EMR can never tell me how to practice medicine!”
• “I don’t really care what’s in the note so long as you leave my narrative alone.”
• “I’m not going to use it.”
  

Many of our Quillen ETSU providers have made similar comments, and who can blame them? Change is never easy, and when that change is implemented with the consequence of “or else,” it’s no wonder that many providers feel bullied into using an EHR.

But what strategies do we encourage our children to use when faced with a bully?  The most common strategy, but one that’s effectiveness has recently been questioned, is to “walk away.”  And questioned rightfully so. A child who walks away from a bully doesn’t make the bully go away. And doctors who walk away—well, they’d just need to find another job, right? —because the EHR isn’t going away.

So what bully strategies do work?  Most experts encourage children to get involved with a another group. With positive peers around, the bully finds it harder to isolate the victim, and, often, the group’s positive influence becomes contagious, even to the point of affecting the bully.

To apply this same strategy to our EHR scenario works as well. Rather than providers giving up, walking away,  and joining the unemployment line, working with the EHR can have some positive outcomes on  our patient population.  With the entire staff on board, and negative attitudes put aside, consider the benefits of using the EHR:

• Patient lists can be generated for better tracking of patient populations, for instance, identifying cardiology patients with low ejection fractions but no ICD.
• Candidates for clinical research trials can be quickly identified.
• The accuracy of medication lists is improved. 
• Order tracking is improved and the cost savings from duplicate orders are passed along to the patient. 
  

Although this is a short list, there are many more benefits that can be added to it. So for those users who  have taken the attitude “If you can’t beat it, join it” or better yet, “I love it,” pass along your sentiments. 

And for those “victims” out there, adopt a new strategy and let  some positive peer pressure affect  you.

*Presentation by Scott Tuning, Clinical Information Systems Manager, New Mexico Heart Institute, Albuquerque, NM

What makes a medication meaningful? I suppose that ANY medication that is prescribed to a patient should be meaningful, but what happens when a patient’s medication list is maintained on the EHR, but the list isn’t accurate? Would an incomplete or inaccurate list be meaningful to anyone?

Let’s for a moment suspend the idea of a medication’s “usefulness” to the patient and examine the “meaningfulness” of the medication’s inclusion on the medication list. Perhaps the best way is to present a few patient scenarios:

Patient Scenario One

Patient One, “Mary Meaningful,” visits a clinic because she has allergy symptoms. She currently takes an over-the-counter decongestant, as well as a few vitamins and supplements. She also takes an anti-anxiety medication that she asks not be included on her medication list. Not wanting to cause Mary any distress, the nurse records her medications in the system (absent the anxiety medication) and sends her on to see the provider. Mary doesn’t mention anything about the anxiety medication to the provider because she feels embarrassed that she is taking it. The provider feels sure the medication list is accurate because it has been reconciled by the nurse and prescribes Mary an antihistamine.

Do you see the potential hazard here?

Dangerous interactions can occur when antihistamines and anti-anxiety drugs are taken together.

Patient Scenario Two

Patient Two, “Mike Meaningful,” shows up for his annual Medicare visit. He reports to the nurse that he has been seeing one of the cardiologists for some heart-related issues and that he was prescribed some medications a few months ago. She pulls up his chart and doesn’t see any medications on the list. When she questions Mike, he tells her that the doctor was too busy at his appointment and didn’t have time to put them in the system.  He just wrote them out on prescription paper.

How meaningful is the medication list now?

One provider’s responsibility has now been pushed off to another provider’s clinical staff, and, consequently, takes more time and is potentially less accurate than using the system the way it was designed.

Patient Scenario Three

Patient Three, “Misty Meaningful,” was originally prescribed 25mg of a blood pressure medication by her primary care physician, which was ordered through the system correctly. A few weeks later, Misty’s blood pressure hasn’t improved so the clinic calls in a higher dosage—50mg—but doesn’t record the change in the patient’s chart. Misty visits her specialist, who sees the dosage is 25mg but knows she is taking 50mg, as she reported to him. He decides she needs to take 100mg, and renews the medication at the higher dose. Unfortunately, Misty has a bad reaction and files a malpractice suit. When the defense attorney reads the specialist’s note, it appears that he upped her dosage by 75 mg because no one recorded the 50mg.

Where does the fault lie? 

Obviously, no one could have predicted the bad reaction, but how can we rely on the accuracy of a medication list and the system’s ability to accurately reflect a provider’s plan when no one takes the time to document in the EHR?

Meaningful Medications = Better Patient Care

I could describe many more patient scenarios in which the lack of accurate medication documentation has caused problems, but I think you get the point. Even when clinics were on paper, keeping an up-to-date medication list was very important for good patient care, but now, with the transition to an electronic health record, and with multiple providers using the same chart, each user must be particularly careful to accurately document. If we strive to make the medication list truly meaningful, the end result can only mean better patient care.
 

I have a “To Do” list of EHR requests, as well as a “To Do” list for all the stuff that needs to be done at home (and both lists can get quite long –with approximately 1200 EHR users and three busy kids!). I’m sure that you also have similar lists.

So, when it comes time to maintain more lists (problem lists, allergy lists, medication lists, etc), I can imagine your response is less than enthusiastic. But lists tend to be generated for a purpose. I know without mine, I would forget many of the things I put on them (and my kids would probably go hungry because I would forget to pay their lunch money). Lists in the EHR, obviously, help us keep up with our patients’ current diagnoses, medical histories, medications, and allergies. With the patient volume many of our clinics handle, keeping lists is essential for providing quality patient care.

That’s why maintaining and reconciling lists is part of the core objectives for Meaningful Use.


Maintain an up-to-date problem list of current and active diagnoses.

Maintain active medication list.

Maintain active medication allergy list.

According to the TennCare website, the up-to-date problem list measure requires that “MORE THAN 80 percent of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient as structured data.” So what exactly does this mean? Simply put, active problems need to be entered on the Clinical Desktop (i.e. electronic chart) for your patients, and if by chance they have no active problems? That needs to be recorded as well (For our Allscripst users, ‘No Active Problems’ should be a quick list item in the ACI). And take note of the word CURRENT. If the patient comes back to see you for a follow up or office visit, and the rash associated with poison ivy from the last visit is still listed as an active problem, then resolve it. If the patient is pregnant—and delivers— then resolve it.

Additionally, “more than 80 percent of all unique patients seen by the EP must have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.” The same requirement is true for allergies.

The Allscripts system makes it easy enough to reconcile these lists, but when you click on Reconcile, remember that you are stamping the list as up-to-date. You must take the time to review the lists with the patient and make sure that all medications and allergies are accurate. Otherwise, when you click on reconcile and you have not truly “reconciled" it, you are falsely documenting in the chart. We have seen time and time again where duplicate meds and expired meds are still on a list that has been stamped as reconciled.

As I mentioned in my last post, clinics must work on office workflows to ensure that someone is going over these lists with the patient at each visit, whether it’s the nurse or the provider.  We encourage spot checking daily schedules and lists to ensure accuracy. And if you can’t remember this recommendation, how about adding it to your “To-Do” list? 

As eligible providers and practices start looking at reporting for Meaningful Use, often, workflows have to be adjusted to ensure that all the requirements are being met for the core and menu set objectives. One of the enhancements to the new version of Allscripts that Quillen implemented in March is the Meaningful Use (MU) Alerts that appear in the encounter summary (assessable by clicking on the red triangle). At the end of each patient encounter, if these alerts do not disappear completely, it’s a good indication that workflows need to be addressed and adjusted BEFORE the reporting period.
Below are some guidelines/suggestions for altering workflows to fulfill the MU objectives.

1. Recording Demographics: Hopefully, this is not an alert that is popping up after the patient is checked in. Demographics are recorded in Experior (the practice management system our organization currently uses), and they are required fields. If you see an alert about demographics, double check that you are on the correct patient, and make sure you access him/her from the Daily Schedule tab.

2. Recording Vital Signs: We recommend that the clinical staff (nurses, medical assistants) enter the vital signs before the patient sees the provider. Most offices already have this workflow in place.

3. Maintaining the medication and allergy lists: This is one responsibility that is still up in the air for many offices. It should be made absolutely clear who will be reconciling the allergy and medication lists. Nurses or providers can do it, but making sure it gets done is essential. We recommend that whoever updates the medical history also reconciles the medications and allergies. Some providers feel more comfortable going over the list themselves, but he/she needs to communicate this to the staff.

4. Maintain an up-to-date problem list of current and active diagnoses: The keyword here is DIAGNOSES, which means this requirement is a provider responsibility. That also means that providers can’t simply “free text” the diagnoses in the note. They have to be added to the clinical desktop. Keep in mind, active problems can be added to the desktop and to the note from within the note, so there is no need to close the note to add them. If the office elects to do so, to save the provider time on new patients (i.e. either those who are new to the practice or new to the EHR system), clinical staff can preload the medical history, and then providers can update histories into active problems. Remember, however, that this only saves searching time. The provider still needs to click on the history item and update it.

5. Permissible prescriptions written by the provider are generated and transmitted electronically. Simply put, STOP USING YOUR PRESCRIPTION PAD. For the current med list to be accurate, scripts have to be entered into the system, either as history or to send to the pharmacy, so there is no good reason to write it on paper. The only time a script should be written out is when the system is down. Eventually, using the system to prescribe will speed up everyone’s workflow because the clinical staff can send per protocol refills by simply renewing the medication from the medication list.

6. Record smoking status: This status should be recorded on all patients 13 years and older. Who should be recording it? Examine the office workflow. It may be easier for the nurse taking vitals to record the information. But if he/she is getting backed up recording all of the other information, then the provider can and should do it —either from within the note or from the encounter summary. Remember, the keyword for searching for smoking status is “Smoke.” Select a status that has “MU” in front of it so that it meets CMS reporting criteria.

7. Provide clinical summaries for patients for each office visit within 3 business days. In last the last blog post, I provided some suggestions for dealing with this requirement. Until a patient portal is put into place, we highly recommend asking the patient at check out if he/she wants a copy of the summary. Postage costs would be too much to mail these out. Familiarize yourself with the output of the document so that you are clear on what the patient receives, and if finishing the note is impossible before the patient leaves, at least get through the plan: Diagnose and Order.

8. Implement one clinical decision support rule. Before the reporting period, the organization will determine what rule will be put in to place and tracked. We recommend getting familiar with the Health Management Profile (HMP tab) and using it to set up reminders for your patients’ health maintenance items.