- When it comes to creating and customizing EHR templates, there is a temptation to minimize the amount of unstructured data by increasing the number of checkboxes and other structured fields. While structured data is certainly valuable and a cornerstone of many of activities performed by primary care physicians, this approach to EHR templates could prove detrimental to other providers, particularly specialists, who have no need for many of the features comprising some of the more popular EHR systems.
“There is a revolutionary divide between the designers and the clinicians,” says Ira Kirschenbaum, MD, an orthopedist by training who also serves as the Chairman of the Department of Orthopedic Surgery at Bronx-Lebanon Hospital and is cofounder of DTC HealthCom. “That’s not anyone’s faults. It’s just a fact. What we need is more people, more things to help bridge that divide.”
From the perspective of an orthopedist, many of the EHR systems designed for primary care go overboard with their templates and approach to clinical documentation. “For many of these programs — whether they’re eClinicalWorks or Siemens — there’s too much structured data. Not everything has to have a click associated with it. The only structured we need is the billing and various events. People emphasize that too much,” argues Kirschenbaum.
What specialists require tends to be much less extensive and in many ways represents a stripped-down version of the off-the-shelf EHR solution:
Take what they have and throw out everything you can’t use as is. If you’re lucky, you’re left with 30 percent. You’re left with a space for your chief complaint, a space for your HPI (your history of present illness). The first note you should build off of that primary care note is a note that is almost entirely contributions from you that are Dragon Dictation. You’re going to spend hours figuring out that the patient blank-zero-blank with right-knee pain blank that hurts blank out of ten, blank out of this. And when you say this, you’re going to have 97 checkboxes and you’re going to be there all day.
Having designed many of his own templates, many of them illustrated in his OMG EMR Template Book, Kirschenbaum has identified the three best templates for specialists and many other physicians for that matter.
The first is the simplest. “My favorite template of all time is a blank piece of paper,” explains Kirschenbaum. “That’s a template.” While this kind of approach obviously lacks sophistication, it is an beautifully simple approach to getting information into the EMR.
Next up is a series of prompts that are constant aspects of the specialist’s clinical workflows followed by a simple colon and a place for the physician to provide the necessary details from the patient encounter “If you can’t succeed at that, you’re in trouble,” adds Kirschenbaum.
Lastly, there’s the integration of clinical notes with coding:
The next level, which is actually a very important one, is to be able to import diagnoses, CPT codes, and treatment codes. If all you ever did was dictate your chief complaint, HPI, and physical exam but then on screen you used the program’s power to code it, what you did in the office, X-rays, and that stuff, you’ve probably got your value from your EMR.
At the end of the day the purpose of EMR systems and clinical documentation is to ensure that the most pertinent information about the patient can flow efficiently from provider to provider. “The things that should be structured are diagnoses, procedures in the office, X-rays in the office, and laboratories. When all is said and done, no one cares that a physician wrote ‘this is a pleasant 60-year-old lady,’” concludes Kirschenbaum.