Clinical MedicinePA Practice

Charting 101: Overcoming the EHR to Document More Efficiently

What’s the worst part of any healthcare provider’s job? Charting. We all hate it. Like a lot. Every one of us has spent nights, weekends, and holidays catching up on documentation. Charting typically involves a computer that separates us from the patient. It usually involves an EHR that is supposed to make life easier but does the exact opposite. And then there’s the never-ending list of worthless legal and administrative requirements that we’re forced to include in every encounter. 

Yes, I have a passionate disdain for every electronic health record or EHR, I’ve used. Not one of them is any good. A lot like political elections, choosing an EHR is about choosing the lesser evil, the one that sucks the least. 

However, the reality is that charting on some kind of EHRs (or EMR if you prefer) has become an integral part of healthcare. It’s not only how we document our own work, but it’s always how we speak to other clinicians, and unfortunately, to third-party payers. 

So, resistance, is I suppose, futile. And rather than resisting them, we need to find ways to make them work more efficiently. So let’s explore strategies to help physicians, physician associates, nurse practitioners, and others, navigate these systems and learn to document more efficiently without sacrificing quality of care or reimbursement. 

The Love-Hate Relationship with Electronic Medical Records

Before diving into strategies for efficient EHR use, let’s acknowledge some of the reasons doctors and PAs dislike them:

  1. Time-Consuming Data Entry

Clinicians are not clerks. We are not secretaries. We shouldn’t be wasting time on data entry. Yet EHRs do not like empty boxes! Did you choose the correct ICD-10 code for your patient’s diagnosis? Did you consider that particular code’s HCC score? Don’t forget to document the appropriate E/M code with any applicable modifiers! Then comes the CPT codes for shots, procedures, and anything you did for the patient. Do you even know what a SNOMED code is? Well, it had better map correctly to your ICD-10 code! 

And don’t even get me started on “clinical decision support” tools that attempt to make sense of payer’s ever-changing rules meant to deny care. 

The modern EHR requires a ridiculous amount of clicking and navigation to input important information and is only one errant click away from perpetuating erroneous information. Garbage in, garbage out. 

  1. Learning Curve

There are literally hundreds of electronic health record systems out there. Hundreds. I’ve personally used 4 but I could easily name a dozen or more. And almost none of them can speak to each other in a helpful, intelligent way. 

Want to make six figures in healthcare? Become an Epic trainer today! Yes, Epic, one of the largest EHRs will pay you upward of $100k a year to teach healthcare workers how to use their gloried manila folder. They actually compare themselves to Homer’s Iliad, yet the most obvious comparison is that both appear to be written in Greek. 

Implementing EHR systems is incredibly expensive and time-consuming. After all, Epic needs to justify its $3 billion annual revenue. They often involve a steep learning curve even for younger, tech-savvy clinicians. I often wonder if a single doctor or PA was consulted in the process. At the end of the day, we must adapt to new workflows and technologies, which can be challenging and time-consuming.

  1. Disruption of the Doctor-Patient Relationship

We’ve already touched on this but EHRs do a disservice to the doctor-patient relationship. I’ve heard it time and time again, “My last doctor didn’t even look at me! She was too busy looking at her computer.” Not only are they a physical obstacle between doctor and patient but they’re an attention suck as any clicking that doesn’t get done in the moment will have to be done after hours. Many of today’s healthcare providers, unfortunately, spend more time focused on a computer screen than engaging with patients and patients do notice

  1. User Interface Issues

User interface design varies among EHR systems and said interfaces are anything but intuitive and user-friendly. To be fair, developers are not doctors and they have to work in government and payer reporting requirements that are the real disruptions to flow. 

But I’m not going to let them off that easy. I can’t even print something from my EMR without first going through a “chart export” feature. How many clicks does that take? One to open the nav, one to open Chart Export, and another to select the method of export (print vs fax or direct). Don’t forget to designate the destination! Umm, me? The patient? You can’t get past that box without entering something. But we’re not done yet. The print preview pops up first and then I have to click one last time to finally get the dumb thing to print. I think the total is 5. 5 clicks and some free type to print. Come on, people.  

  1. Software Bugs

Like any software program, there are updates. And with updates come bugs. My current EMR, Athena, is buggy as hell. I’ve been using Athena for about 5 years. And I used to say that it was the best EMR I had used (don’t confuse that with a good EMR, only the least crappy). 

But the more I use it, the more buggy it gets. I just love making a referral and trying to attach records because, without fail, I will get kicked out of the drop-down menu the first time. Without. Fail. I’ve stopped reporting bugs because the tech support is awful. They can never replicate what I, and other clinicians in my office, are seeing daily. 

I cleared the browser cache, tried a different browser, tried to configure the browser per their recommendations, and downloaded whatever file I was supposedly missing, and still, it’s riddled with bugs. To be fair though, I’m sure it’s not just Athena. But I could go on for days about the troubles I have with it and yet it is still probably one of the better ones out there. That’s sad. 

Collaboration and Communication: The Benefits of Electronic Medical Records

Efficiency in EHR use is not just about individual practices; it’s also about fostering collaboration and communication among healthcare providers across specialties and institutions. Here’s how:

  1. Interoperability

Advocate for interoperability between EHR systems. The ability to share patient records seamlessly across different healthcare settings can save time and enhance patient care.

Interoperability can reduce duplicate testing and improve care coordination, resulting in better patient outcomes. Our state has a database to which anyone can upload their clinical notes. As primary care providers, we have also been given read-only access to the records for 2 major hospital systems in our area. 

  1. Standardized Communication

Standardize communication protocols within your healthcare facility. Establish clear guidelines for sharing information within the EHR system to ensure that all team members are on the same page.

Standardization can streamline communication, reduce errors, and save time that might otherwise be spent deciphering unclear or inconsistent messages. Does your practice have protocols for when a patient calls into the practice, for example? 

  1. Use EHR for Care Coordination

Leverage the capabilities of EHRs for care coordination. Use the EHR to communicate with specialists, nurses, and other members of the healthcare team. Share relevant patient information, test results, and treatment plans electronically, reducing the need for time-consuming phone calls and faxes.

Strategies for EHR Efficiency and Documenting More Efficiently 

Okay, down to business. Let’s figure out what can be done to make our lives a litter bit easier right now when it comes to charting. While it’s valid to acknowledge the challenges, it’s equally important to recognize that EHRs can be harnessed for greater efficiency and time-saving in clinical documentation. Let’s explore strategies to turn the EHR challenge into an opportunity:

  1. Customization

Many EHR systems allow for customization to tailor the interface and templates to individual preferences. Athena has macros or “dot phrases” that allow the clinician to easily reproduce common phrases. Take advantage of these features to create a more user-friendly and efficient workspace.

Consider working with your IT department or EHR vendor to customize templates and workflows to match your specific practice needs. Customization can help reduce time spent navigating through irrelevant fields and screens.

  1. Dictation and Voice Recognition

Voice recognition technology has come a long way and can be integrated with EHRs. Instead of typing out notes, consider using dictation software that converts your spoken words into text. This approach can save considerable time and alleviate the burden of manual data entry.

  1. Be Brief

Clinicians are all taught to get a comprehensive history of present illness, or HPI. Most of us learn to take a chronological approach, highlighting the pertinent positives and negatives. The problem with this approach is that it takes time to write nice, complete sentences and create a clear narrative. So don’t. At least don’t waste time on perfect grammar and complete sentences. 

For example, you could write an HPI like this: Mrs. H is a pleasant 47-year-old white woman with a history of type two diabetes, hypertension, and coronary artery disease who presents today to discuss her recent addition of insulin after an episode of chest pain that was subsequently diagnosed as a myocardial infarction. 

Ok, it sounds good. It’s very clear. But it takes too much time. Consider this: 47 yof T2DM, HTN, CAD sp STEMI w/ DES x1 2 Sept 23. Recent add glargine 15 U. AM BG 130s. No hypos.

In half the amount of time and space, I’ve communicated a lot more information. When I was in school, we were warned about using too many acronyms. We were told it could create confusion and lead to errors. Ok… maybe? Or maybe it’s the only way to survive in the real world. 

  1. Delegate

Consider delegating some EHR-related tasks to scribes or trained medical assistants. Having a skilled scribe enter data and complete administrative tasks while you focus on patient care can greatly enhance efficiency.

Though it may seem obvious, delegate appointment scheduling and administrative updates, to support staff. This allows you to focus on clinical documentation and patient care.

  1. Pre-Visit Planning aka The Huddle

Prepare for patient encounters either the day before or the morning of by reviewing relevant patient records with your support staff. Update any templates before the appointment. This can help you streamline data entry during the visit, reducing the need to hunt for information during the patient encounter.

While an actual huddle may be difficult to coordinate, take a minute before each appointment to review and even carry over data from the last appointment. Especially helpful in chronic care management, our EHR has a “forward” function to duplicate the last HPI, review of systems, physical exam, and the assessment and plan.

So, rather than create a new HPI from scratch for each visit, I keep a running log of their diabetes care, for example, and simply start with the word “today”, to indicate which information is the most recent. It saves a ton of typing and functions like a 3-6 month lookback into each chronic diagnosis. 

  1. Mobile EHR Apps

If available, explore mobile EHR applications that allow you to access patient records and complete documentation on a tablet or smartphone. These apps can be especially useful for on-the-go physicians, enabling quick and efficient documentation without being tethered to a desktop computer.

  1. Continuous Training

Invest time in continuous training and education on your EHR system. Understanding all the features and functionalities can help you work more efficiently. Stay updated on system updates and enhancements that may improve your workflow.

Maintaining Quality in the Age of EHRs

Efficiency should not come at the cost of quality in clinical documentation. But remember that you determine what constitutes quality documenting. In my mind, quality means comprehensive. I want to see as much relevant data as I can without having to probe the dark recesses of  the chart  Here are strategies to ensure that quality is not lost:

  1.  Structured Documentation

Embrace structured documentation templates within your EHR system. These templates guide you to capture essential information systematically, ensuring that nothing critical is missed while streamlining the documentation process.

Structured templates can also help ensure consistency in documentation, making it easier for other healthcare providers to interpret your notes accurately.

  1. Review and Close

Allocate time at the end of each patient encounter to review and edit the EHR-generated notes. Ensure that the documentation accurately reflects the patient’s condition, your clinical findings, and the treatment plan.

Document as much as you can during the actual encounter to capture the most accurate information. Ideally, you would close, or sign off, on the encounter before seeing the next patient. 

  1. Avoid Overuse of Templates

While templates can be efficient, avoid overusing them to the point where documentation becomes overly generic. Customize templates as needed to capture the nuances of each patient’s condition.

  1. Maintain a Patient-Centered Approach

Even while using EHRs, prioritize maintaining a patient-centered approach. Engage with your patients, involve them in the documentation process when appropriate, and ensure they feel heard and valued.

Conclusion

While the frustrations with EHRs are valid, they are not going away anytime soon. Doctors and PAse can take steps to turn this challenge into an opportunity for greater efficiency and time-saving in clinical documentation. By embracing customization, technology, and delegation, we can optimize our EHR workflows. 

It’s essential to strike a balance between efficiency and maintaining the quality of clinical documentation. Finally, promoting collaboration and communication in the healthcare ecosystem can further enhance the benefits of EHR systems. In this digital age, EHRs are here to stay, and by mastering their use, we can continue to provide high-quality care while efficiently managing documentation requirements.

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