• Oct 14

    Versio Staff

    EHRs Can Place Excessive Data Entry Burden on Physicians

    by  Versio Staff

    Required Structured Data Only Small Percentage of Typical Patient Note

    The study indicates that as little as 7% of data in a typical patient note is required to be structured in order to meet Meaningful Use. The percentage rose to 9% when lab data was present.

    The study analyzed one hundred de-identified orthopedic and cardiovascular patient notes obtained from MTSamples.com.

    While a larger body of documents needs to be analyzed to confirm study findings, the key takeaway appears to be that as much as 91% to 93% of data typically captured within EHRs in a structured format (e.g. point-and-click templates and drop-down boxes) could instead be captured as unstructured data (e.g. dictation and transcription, or free-text entry) and still meet Meaningful Use requirements.

    "This study is especially relevant for physicians frustrated by the negative impact EHRs can have on their patient interactions and their productivity," said Mark Christensen, WebChartMD's CEO. "Physicians are often asked to capture more data in a structured format then Meaningful Use requires."

    Data required to be structured for Meaningful Use are:

    • • demographics (preferred language, sex, race/ethnicity, date of birth)
    • • vital signs (height, weight, blood pressure, BMI)
    • • smoking status
    • • problem list
    • • medication list
    • • medication allergies
    • • lab tests/values
    • • minimum of one Family History entry

    According to Elisbeth Myers, Policy and Outreach Lead at the CMS, much of the data routinely documented as part of the patient encounter – such as the History of Present Illness, Assessment, and Plan, to name a few key document sections – can be incorporated into the patient record within the EHR as unstructured data without in any way preventing the physician and clinic from meeting Meaningful Use.

    "Too many physicians struggle with their EHRs when they simply don't need to be," said Christensen. "A greater use of dictation and transcription could represent a faster and easier means of documenting large portions of their patient encounters."

    Adding dictation and transcription is easier than many physicians realize. "Virtually every EHR is capable of incorporating transcription into the patient note via what's called an interface," said Nathan Mitchell, WebChartMD's Operations Manager. "Setting up an interface can take anywhere from 30 minutes to six weeks, and requires the cooperation of the EHR vendor."

    WebChartMD (www.webchartmd.com) is a software development company specializing in clinical documentation workflow applications.

    Versio has been in the clinical documentation business since 2000, and is passionate about accurately capturing the patient story. For more information on how your physicians can incorporate dictation and transcription into their EHR workflow, please visit us at www.MyVersio.com or email sales@myversio.com. Versio also offers several options to fully support your needs for data that does need to be structured.

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