I’ve been a physician for nearly 15 years, and have seen the tides of change affect healthcare and the practice of medicine. It is not an easy job, and regulations are not making it any easier. Working in emergency department, I deal with a roulette of acute health crises on a daily basis, the least of my concerns should be documentation. My and my colleagues’ primary focus is on helping our patients and increasing their chances of survival or limiting their severity of illness.
While I see the importance of some of these regulations, I firmly believe that if technology is to be mandated, it needs to be absolutely intuitive. When a 45-year-old man suffering from a heart attack is brought into the ED, we on the care team know what to do leveraging our training and strength through teamwork. Through training, technology and teamwork, the practice and art of medicine becomes instinctive and intuitive. Clinical technology needs to be the same.
New year, new challenges
Regardless of which Meaningful Use stage you currently find yourself striving for, regulatory mandates have placed a weighty administrative burden on physicians. Believe it or not, we find ourselves (once more) gearing up and counting down to October 1, 2015 and the ICD-10 transition. Although the specificity and intent behind ICD-10 is important and valuable, the transition comes with three times the number of medical codes, some very real productivity losses, and the potential for high levels of clinician frustration. And at the epicenter of it all, is the patient story.
When it comes to health information technology, one of the biggest concerns is getting the patient’s story accurately reflected in the record. This doesn’t just mean clinically. Now with ICD-10, there is an increased focus on getting billing codes correct up front, as well. One way healthcare organizations are helping to mitigate these pressures is by providing versatile technology to their clinical teams that support a rapid pace and accuracy of the patient’s record up front. Allowing physicians to have a choice in the technology they use, for instance how they document their patient notes, can help expedite their workflow. Here are a few examples of physicians making IT work for them:
Dr. Brian Levine is a reproductive endocrinologist at New York Presbyterian Hospital and usually sees 50 patients a day, so accurately documenting his patients’ story efficiently is essential. He relies on speech recognition: “I can dictate a note before most people think about writing one,” he says. If there is a mistake, he tells the program where the mistake was and how to fix it, if there is a need to search for an ICD code, he can do that, too.
Partnering with patients to provide better care
Physicians are also using their clinical documentation as a way to involve their patients in their own care. “The electronic revolution in healthcare has allowed a shared and more collaborative relationship to develop,” says Dr. Steven Schiff, CMIO at Orange Coast Memorial Medical Center. “The more patients understand, the better their ability to participate in their own care, and the better their personal choices will be. I have been using EHRs as a tool to help explain and work through health issues with my patients.”
Dr. Levine, too, dictates in front of his patients during their office visits. Doing so enables him to engage with the patient, “They hear key things,” he says, which is important to them becoming more informed about their care. Additionally, it saves time he would have spent entering the note non-verbally.
At the heart of great care is compassion and good information. Technology that fosters the physician-patient relationship and expedites the accurate capture of important health information into the EHR is the key to driving better healthcare. It shouldn’t matter how a clinician chooses to document, as long as it can be done quickly and in a way that allows information-sharing with patients, so they can better understand and become partners in their own health, and with other providers and care teams throughout the continuum of care, so the most informed clinical decisions can be made.