Let’s not forget the patient

 By Linda Allard

 

Recently I had the unfortunate experience of spending approximately 3 months between a hospital and a rehabilitation facility. I spent two weeks in ICU and a week in the CCU with my husband who was critically ill.

This particular hospital had a full-scale EMR system. Although I truly believe we need to embrace technology, what I learned from my experience is that being a family member in this type of facility was difficult. I felt as though I spent much of this time dealing with a computer, not a health practitioner.

Now I am no stranger to a computer and very comfortable being around them — after all, I spend the majority of my day on a computer. However, I do think that as we all move forward with our EMRs and bedside computers we must not forget the patient and their family.

Dealing with a critically ill patient is hard enough. Dealing with a critically ill patient and losing the connection with the doctors and nurses because they speak to the computer, type directly in and no longer have eye contact with you is even more difficult.

Don’t get me wrong, I know that we need EMR systems in the hospital. I think doctors and other patient care providers need as immediate access to the record as possible. I know that having an electronic record can allow specialists to gain valuable insight into the patient quicker than a paper chart, especially when another doctor might have the chart checked out.

I just want my doctor to look at me. I need to see his face and understand if my husband, who is not able to speak to me, is ever going to again. I’m not going to see this and feel this when the doctor walks in, rolls the computer over and starts to read and then type in things as he speaks with me.

There needs to be some balance between the new technology and patient care. There needs to be a balance between doctors dictating reports and having them transcribed by a medical language professional and trying to save the hospital money by typing while with the patient.

As we watch medical records and health care evolve, we all need to remember no matter what our role is, that what we ultimately do is give good patient care and take care of patients in the best possible manner.

We’re eliminating transcription.

                                                                                      By Rick Bisson

Participating in healthcare related conferences and talking with prospective clients, I hear many people say that they are eliminating transcription.  They point to their electronic medical record, front end speech and other means to reduce transcription and the associated cost, but that’s not where the conversation ends.
Admittedly, they haven’t eliminated all transcription … certain specialties, practices or doctors are still relying on transcription.

Then when the conversation progresses to the practicality of the facility’s highest income producing assets – who are also the highest paid staff members – spending up to two hours a day doing clerical work, there is general agreement – maybe that’s not the best use of their time.  Not only are these highly educated and skilled providers typing their own reports, they are also responsible for editing and correcting any errors or omissions.  Ask yourself: Is this a best practice for a health care provider?

And what about errors and omissions?  Certainly the doctors typing, cutting and pasting and clicking are well intended but doesn’t their responsibility to accurately document the patient’s encounter create legal liability? With the advent of the electronic medical record, isn’t there heightened exposure?  As each of us gains greater access, awareness and involvement in our own medical records and those of our loved ones, we will become critics of the documented narrative in our reports.  Soon many of us will have an electronic folder on our desktop computer, or in a shared folder on Dropbox.  From time to time we’ll review the reports, especially before or after appointments or surgery.  If we find errors or omissions then we’ll be quick to expect corrections.  Some may be quick to take advantage for any potential financial gain.

Inevitably the topic of ICD-10 emerges.  Clearly ICD-10 increases the need for more specificity of the patient encounter.  Will this increase the provider’s narrative and increase the need for editing?  Most agree it will.  Are providers going to spend more time as typists and editors and less as healers?  Will they be rushed to cut and paste more, thus reducing the individual narrative specific to each patient encounter?  Could this lead to more errors?

Now don’t get me wrong, certain routine functions within the EMR and advancements in dictation options speed the delivery of patient information.  More on that topic will be covered in a future posting.

The end game is the creation of a document summarizing a patient encounter.  This document becomes a permanent addition to the patient’s health record.  The accuracy and clarity of this report is critical to the immediate and future care of that patient.

What better system exists to effectively and efficiently permanently capture the patient encounter than a provider dictating their report and a skilled transcriptionists or editor finalizing the document?

What do you think?