American College of Physicians offers tips for better EHR system usage

American College of Physicians offers tips for better EHR system usage

When it comes to achieving meaningful use of patient information, selecting the best EHR software is essential. However, there’s more to it than choosing the right technology – providers must learn to embrace advancements in healthcare IT and properly use new technologies for the betterment of EHR usability and efficiency. That was the topic of discussion in a new paper published by the American College of Physicians in the January 2015 issue of the journal Annals of Internal Medicine.
The paper examines the evolution of clinical documentation in the current century – past advancements and indications of what’s to come. The authors note that existing technology like patient portals, registries and home monitoring devices are likely to be integrated into EHR systems in the future, and demand and feedback from physicians will be key in driving such improvements.
“We believe that physicians must help define and prioritize the many important roles that clinical documentation serves today,” the report’s authors wrote. “The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.”
Suggestions for using EHR software
The report also provided a handful of recommendations for providers, policymakers and IT developers in regards to enhancing EHR usage. When it comes to clinical documentation, physicians should understand that the main purpose is to deliver quality patient care and improve care outcomes. To do so, the ACP suggest that healthcare organizations implement these professional standards in their clinical documentation practices:
Patient records should include as much detail as possible required to retell the story without providing excess information unnecessary to the clinical process.
Templates and macros should be used in appropriate situations to help make documentation as complete and efficient as possible. This may be best suited for situations when records require only standardized terminology, such as when reporting physical exam results.
Clinician software training should be ongoing and exhaustive to keep providers up to date on new technologies.
During the medical document management process, the “review/edit: and “copy/forward” functions may be useful when clinical data is still relevant and accurate and any added information improves the accuracy and completeness of documentation; however, such functions should be used carefully as they can often weaken documentation.
Overall, the main goal of such suggestions is to avoid overloading EHRs with extraneous information that diminishes the value of patient records by allowing the important data to be lost win a bevy of unnecessary data. Keeping documentation direct, to-the-point and appropriately detailed can help ensure that you get the most out of your EHR software and in turn, can help providers deliver quality care for the betterment of both individual and population health.

Laser Focus on EHR

Laser Focus on EHR – Nope, Patient

EHR vendors are starting to catch on. The challenge is how to provide the technology doctors want in a demanding regulatory environment.

There’s a lot of buzz about the new ZDoggMD rap “EHR State of Mind” ( this week.  And, there’s good reason. Physicians and other medical providers have been saying that they hate the ’electronification’ of healthcare for several years. The software space is dominated by big company vendors providing overly robust systems positioned as “changing” or “driving” healthcare. The movement is driven by a bureaucratic initiative mandated at the federal level, touted as an opportunity to drive improved population health. What started as a legitimately good idea has become a travesty in the healthcare delivery system, causing frustration for everyone involved from patients to providers to vendors and even those who conceived the plan that still could produce beneficial outcomes through real world data collection and analysis.

No doubt, records technology provides great benefit for the medical field. Software has the capability to improve patient care, health outcomes, provider and business efficiencies. Clearly, we’ve gotten sidetracked.  Nearly four decades ago EHR was a facilitator in the hospital setting and, Dr. Clem McDonald from the Regenstrief Institute succinctly stated the goals for electronic health records:

“Our goal was to solve three problems: (1) to eliminate the logistical problems of the paper records by making clinical data immediately available to authorized users wherever they are – no more unavailable or undecipherable clinical records; (2) to reduce the work of clinical book keeping required to manage patients – no more missed diagnoses when laboratory evidence shouts its existence, no more forgetting about required preventive care; (3) to make the informational ‘gold’ in the medical record accessible to clinical, epidemiological, outcomes and management research.”

The goals stated by Dr. McDonald are really the same today, but with much more inclusive scope. As EHR expanded to the ambulatory providers, vendors quickly discovered that hospital systems were not well suited for ambulatory providers. To meet the needs of ambulatory providers, software needed to provide more physician specific workflows, less sophisticated IT administrators, and better interfaces to provide and accept information from labs, diagnostic devices, etc. New vendors entered the market and developed solutions that worked, but not necessarily together. There was no standardization, largely reflective of the user markets to which vendors catered. In short, the advancement of emerging EHR technology stalled as the direct costs to clinicians outpaced the direct benefits to their practices. Here, government stepped in to attempt to fill the gaps by setting standards and incenting providers to continue to invest and adopt technology solutions to advance electronic health records to meet those original goals. HITECH set standards and certifications aimed at meeting those goals defined and incented through Meaningful Use. Vendors have struggled to keep up with the regulatory compliance of these programs, even as they incorporate additional regulatory requirements such as HIPAA and adapt to user preferences and requests. Added up, EHR technology requires high investment by vendors which is passed on to providers, who increasingly struggle with the robust adaptations to meet certification requirements. The focus and attention required to stay current with the administrative technology changes are distractions from the primary purpose of the providers.

We get it ZDoggMD. There are some vendors out here that understand your frustration. We are a little smaller than the groups that dominate this space, but still provide top tier, customizable solutions. MDsuite has maintained a focus on “ease of use” and “great support” for more than three decades. At our recent user conference, clients cited these two areas as the top reasons they like our product and us. MDsuite, like the other vendors, has had some growing pains as we continue to adhere to the gargantuan amount of regulations in healthcare. We believe our approach to service is what has kept our customers loyal and satisfied. At MDsuite, we join you in applauding Athena for jumping on the wagon to admit that EHR needs to improve its ability to meet your needs. Finally, a big vendor is moving to a direction we have always believed to be right.