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A Physician’s Response to EHR and the Need For Digital Documentation

It’s no secret that the emergence of electronic medical records (EMR) has forever changed the way physicians document and access patient information. But just how much have these systems changed medical documentation? We interviewed Dr. Sana L. B., a neurologist with almost 40 years of experience to learn his thoughts on the evolution of EHR and how it has changed his role as a physician.

How EHR Has Changed Medical Documentation

For a physician with nearly 38 years of private practice experience, the evolution of medical dictation is clear. From paper to electronic, we asked Dr. Sana B. how his role in the medical practice has changed since the introduction of EHR.

As the EHR was introduced, it became more and more difficult to practice,” Dr. Sana B. said.

EHRs, regardless of their interoperability and accessibility benefits, seem to take the personalization out of documentation. Because of the required fields needed to create such intricate data, physicians are no longer able to personalize notes in such a way that helps them–as well as patients and fellow physicians–understand their intent.

When asked to compare his medical documentation between paper and electronic records, Dr. Sana B. said, “My reports were a work of art. I would dictate based on the history, physical examination, and then a full analysis of the situation with a review of systems and social history put into a beautifully dictated report, which no longer exists now, but now becomes a standard computerized situation.”

From works of art to cookie-cutter computerized data, there’s no doubt that EHRs have changed medical documentation. What’s changing even more, though, is the amount of IT and data requirements that come along with them.

The Technical Issue With EHR

Technology across all industries has grown tremendously over the past decade. And while the advancement of technology in medicine has provided some amazing benefits, it has also created some serious gaps.

Take EHRs for example. We’ve already learned that EHRs have taken away physicians’ abilities to personalize their data. But what else is it affecting? Dr. Sana B. gives us an insider’s opinion on some of the technical issues that come with EHR.

“In the past ten years, I actually gave up my practice and joined a multispecialty group because it was becoming too tedious to handle all the IT requirements.  When my computer would go down, I would have to call my [IT] company, which then would sometimes take a day or two to take care of the problem. By joining a multispecialty group, they have IT people on the premises.”

Unlike paper records, the retrieval of electronic medical records is completely dependent on the functionality of the system. Therefore, if there is a technical issue with the system it becomes a huge issue in documentation and access to records. A large practice with an in-house IT team has the advantage of working through those errors quickly, while a smaller practice without those resources might not.

“I will also point out that if a computer goes down, you cannot see the patient,” said Dr. Sana B. “If you lose a [paper] chart on a patient, you lose only one chart and you could see the other 25 patients that are scheduled for the day, but if the computer system goes down, sometimes it goes down for no fault of ours, but because the internet provider goes down, we cannot see patients.”

EHR and Its Effect On the Patient-Physician Relationship

Dr. Sana B. mentions what he calls “very weak points” in the EHR system in regards to its effect on the patient-provider relationship. Because of the complexity of the system and the amount of time it takes to fill out the system’s forms, the amount of time a physician spends charting the information is much higher (in comparison to paper charting).

Because of this, physicians are forced to focus most of their time on ensuring their notes are accurate, instead of focusing more on what’s most important–the patient. Not only does the physician’s lack of time affect the patient experience during the visit, but it also interferes with scheduling. Typically, a physician will spend several hours going through their EHR and editing or adding any necessary information.

Dr. Sana B. adds, “we always have patients who are clamoring to see us and there is no one that I know of in my practice of neurology that does not have a 2-3 month waiting list.”

With all of this time spent in the EHR, physicians are having to push their appointment dates out for months and months, leaving even more time between them and their patients.

So what can be done to fix these issues?

Pairing Medical Transcription With Digital Documentation

Since EHRs certainly won’t be going away–and because we can’t deny the benefits the that EHRs do provide to healthcare–there must be a solution for physicians and their practices. According to Dr. Sana B., the trick to remaining productive and precise as a physician is by hiring a medical transcription company to assist with dictation.

Medical transcription services allow the physician to speak into an electronic device linked to a skilled medical transcriptionist who types each word into a document or directly into the EHR system. The physician can then review the document, sign it and authorize it as an accurate chart record.

At DataMatrix Medical, we provide accurate medical transcription solutions that easily integrate with your current workflow.

Having worked with DataMatrix Medical for nearly eight years, Dr. Sana B. gave us some expert feedback on our services and their effects on his practice.

“I know it changed my life. I have always used transcript modalities, and when the hybrid system was created, it prevented me from retiring basically because I could never type as fast, I never could have done any of this EHR input that is being done.”

So whether your practice is new to EHR, or you’ve been utilizing it for years–it may be time to step back and take a look at the effectiveness of your system. Start by asking yourself these three questions:

  1. Is my EHR slowing me down?
  2. Is EHR interfering with my relationship with my patients?
  3. Am I struggling to produce accurate records in a timely manner?

If you answered yes to any of these questions, it may be time to consider medical transcription for your practice. Visit our website to learn more about our medical transcription services.

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