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With a few tweaks and some patience, EHR technology won’t remain burdensome.
There are many reasons why pediatricians are adopting electronic health record (EHR) systems. Pediatricians can become eligible for enhanced insurance payments by using their EHRs to gain patient-centered medical home (PCMH) status. Some pediatricians with more than 20% of Medicaid patients in their practice are receiving incentive dollars from the government for demonstrating meaningful use of an EHR. Other pediatricians have adopted their EHRs to become eligible to join Accountable Care Organizations (ACOs), which require EHR-generated data proving that the practice is achieving quality measures.
In my view, the best reason for adopting an EHR is that it enables practices to take better care of their patients. However, as evidenced in Contemporary Pediatrics’ “First Issues and Attitudes Survey” published in December 2013 (Contemp Pediatr. 2013:30(12):24-32), 43% of pediatricians using EHRs consider them an “ineffective and burdensome technology,” and 21% of pediatricians are on their second EHR while 5% are on their third. This is very unfortunate, because an EHR should improve, not hinder, your workflow and productivity.
With more than 750 EHRs to choose from, it is easy to implement the “wrong” EHR for your practice style and workflow. In this article, I’ll detail how to effectively use your EHR. I’ll also discuss which EHRs you should consider adopting if you are planning to switch EHRs.
The ergonomics of your exam rooms have an immense impact on how you use your EHR (Table 1). In my opinion, the most efficient setup of an EHR involves workstations in each exam room, positioned strategically so you can view parent and patient while inputting information into the EHR. Having a workstation with a computer stand, comfortable seat, large screen, mouse, and keyboard makes it easy to input information. Better yet, have a printer in each exam room, so that you or the nurse or medical assistant who rooms your patient can provide school notes, physical forms, and instructions without leaving the room to retrieve them from the printer down the hall.
Computers and printers are inexpensive nowadays so don’t be foolhardy and skimp on this important expense. With a little effort and some Velcro, you can childproof your computer workstation. Obviously, you must learn good computer habits and lock the screen when leaving the room so children, even those with inattentive parents, won’t be tempted to play with the computer. In many years of EHR use, I’ve never had any children damage computer workstations.
Documenting a patient visit in an EHR is a collaborative effort among receptionist, rooming nurse or medical assistant, and provider. The receptionist should print out a “previsit” summary for the patient that includes demographic information, problem list, current medications, and upcoming appointments. The parent can review this information while in the waiting room, and when the patient is roomed, any corrections or additions can be inputted into the system. You need to expedite the taking of vital signs and screening tests by having scales and all equipment available in the room.
Workflow efficiencies have been discussed in 2 previous installments of Peds v2.0 (See “Thinking inside the box: Optimizing office workflow” [Contemp Pediatr. 2013;30(3):41-44] and “Improve your practice: Keep it simple!” [Contemp Pediatr. 2014;31(1):36-39]). A trained and efficient rooming staff will measure patients, take vitals, perform age-appropriate screening tests, and preprint all necessary forms so that you can hand these to the patient at the conclusion of the visit. Additionally, nurses will perform urine dips and strep tests when appropriate. Lastly, they can also put in chief complaint and input orders for the immunizations to be given at the conclusion of the visit. It then becomes a simple matter for you to input the history of present illness; pertinent physical findings; assessment; and plan, and generate prescriptions, labs, and orders for diagnostic studies or referrals.
If you did your research prior to investing in your EHR, you can expedite entry with macros, utilize visit templates, and even dictate portions of your notes using a voice recognition program before leaving the exam room. Many programs support the use of check boxes for information entry. Find the most efficient way to document your portion of the medical chart using any means necessary. You should not be writing a tome, but a note that meets all required elements of either a level 3 or level 4 visit, so that you will pass insurance company audits. (See “Level 4 office-visit coding” [Contemp Pediatr. 2013;30(2):37-41].) Well visits can be documented most easily by maximizing use of templates that integrate check boxes into the chart note.
Let’s face it-some pediatricians’ computer skills are better than others. For some our EHRs have just too many buttons to click, and others find charting in an EHR “ineffective and burdensome.” Technology-phobic pediatricians might consider hiring a medical office “scribe.” Scribes are often paid as much as $20 per hour to shadow a physician throughout the day and generate all chart notes that the physician will review and sign.
There are national companies, such as ScribeAmerica (Aventura, Florida) and ScribeConnect (Carbondale, Illinois), that train and certify interested individuals to work in medical offices as scribes. Interested physicians can google “scribe medical services” and talk directly with these companies to learn the nuances of using scribes in their offices. Studies have shown that using scribes in a medical environment improves patient satisfaction because physicians can concentrate on communicating with patients rather than being distracted by the EHR. Scribes also improve productivity substantially. In most instances, the additional revenue will more than cover their addition to your staff.1,2
Most of the better EHRs incorporate 1 or more mechanisms to facilitate the entry of information into the EHR by using shortcut tools. Typically, these include pick lists or dot phrase macros that prepopulate chosen fields. You need to practice and experiment with your EHR system so you can learn to navigate and enter data quickly.
It also may be worth your while to investigate the use of inexpensive programs such as PhraseExpress (Bartels Media GmbH; Wittlich, Germany) that can help expedite documentation by providing key combination shortcuts to insert sentences or paragraphs quickly. There are other programs, including Macro Express from Insight Software Solutions (Kaysville, Utah), that can be used to automate repetitive actions in your EHR such as assigning a diagnosis and procedure code as well as checkout instructions.
If, after everything is said and done, you have made the decision to migrate to a new system, the most difficult decision is which EHR to select. Consider a pediatric-specific EHR such as Office Practicum (Connexin Software; New York, New York) or the Physician’s Computer Company’s EHR (Winooski, Vermont). Seek opinions from other pediatricians using EHRs by joining the American Academy of Pediatrics Section on Administration and Practice Management and enrolling in its listserv. You can also be guided by current surveys and ratings and choose an EHR that has been successful in the marketplace and well rated by physician users.
Medical Economics, the sister publication of Contemporary Pediatrics, recently dedicated an entire issue to the top 100 EHRs (October 2013) and is well worth your review. According to an article published July 8, 2013, on the Medical Economics website, just a handful of EHRs have proven to be the most popular among physicians in small practices.3 These are listed in Table 2.
If you are thinking of changing EHRs, I would keep in mind that the EHR marketplace is currently somewhat in turmoil because many vendors won’t have the resources to meet the stringent government requirements for meaningful use stages 2 and 3, coming in the years ahead. As a consequence, many companies will merge or leave the marketplace altogether.
Also, consider that beyond hardware costs, most EHRs are very expensive. I have watched Practice Fusion (San Francisco, California) become a popular EHR among primary care providers and would strongly consider adopting this “cloud-based” system if I were switching. Unique among its competitors, Practice Fusion is both free and “fully functional,” and the online tutorials I’ve viewed are quite compelling. The software is supported by advertisements that do not hamper workflow. The program is currently certified for meaningful use stage-2 status; the company is well funded; and this system continually rates high in physician EHR satisfaction surveys. Furthermore, the program supports electronic prescribing and interfaces with many national lab services as well as billing services.
By implementing the efficiencies discussed in this article, I am optimistic that many pediatricians will improve their workflow and perhaps even enjoy using an EHR. However, if it’s time to make a switch, learn from your missteps. Do a good job of researching your options and choose wisely.
1. Bank AJ, Obetz C, Konrardy A, et al. Impact of scribes on patient interaction, productivity, and revenue in a cardiology clinic: a prospective study. Clinicoecon Outcomes Res. 2013;5:399-406.
2. Arya R, Salovich DM, Ohman-Strickland P, Merlin MA. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17(5):490-494.
3. Glenn B. Top 10 most popular EHR systems for small practices. Medical Economics. http://medicaleconomics.modernmedicine.com/medical-economics/EHR/HIT/10-most-popular-ehr-systems-small-practices. Published July 8, 2013. Accessed February 21, 2014.
Dr Schuman is adjunct associate professor of pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire. He is also section editor for Peds v2.0 and editorial advisory board member for Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.