HMI 7430 Main Street is a three-physician family practice that implemented an EMR several
Main Street Family MedicineHMI 7430Main Street is a three-physician family practice that implemented an EMR several weeks ago, which led to tension among staff.Dr. Smith had traditionally dictated his chart notes and has kept doing so. Before the visit, he has the staff print out a copy of the lastvisit chart note for the patient, along with any faxed copies of lab test results (or results in the system) for that patient. At the timeof the visit, he has the nurse write down current vitals and medications on a paper form arranged into sections. He then carries thispaper and the old note into the exam room. In the exam room Dr. Smith dictates to a Dictaphone while talking to the patient. Somepatients find this awkward. He doesn’t use a computer in the exam room at all. He writes all prescriptions out by hand on paper andgives them to the patient at the end of the visit. Later that day or the next day, a transcriptionist types up the note directly into theEMR, and enters the patient vitals and meds from the paper form. Dr. Smith then has staff print this new note out; he reviews it andsigns it, after which the signed copy is scanned into the EMR. He still uses a paper Superbill form to code for billing. He finds the newEMR more of a nuisance than anything else. He has a desk computer in his office but uses it only for email. His notes are beautifulnarratives, neither too long nor too short. Dr. Smith usually reviews and signs his notes at the end of the day.Dr. Jones used to be in the habit of jotting down a few handwritten comments in the paper chart while seeing the patient and thendictating his notes at the end of the day. This enabled him to spend a lot of time with his patients, but it also meant he finished up at7 or 8 o’clock every evening. Now, with the new EMR, he is trying to change the way he works. Before he sees the patient, he has anurse start a note and enter the vitals and current meds directly into the EMR in a data entry screen. The nurse also checks to see ifthere are any lab test results in the system (some labs interface with the EMR) or that have been faxed. Then when in the examroom, Dr. Jones looks up the previous visit note on a laptop when he first sees the patient, looks at the lab results, then looks at thenew note, and points and clicks on items during the visit to complete a note that looks more like an outline than a traditional note.He tries to finish most of the note at the end of that visit, before seeing the next patient. Dr. Jones has the nurse enter prescriptionsand orders into the CPOE module, and then he signs them and sends them. He tries to use the system to code the visit level forbilling but seems to be undercoding since he is afraid to make a mistake and is still learning the system. He likes how the EMR haschanged his work style, because he doesn’t have to rely so much on memory. But he sees 20% fewer patients than before and hisrevenue per patient is lower than it was before. Also, sometimes he doesn’t get around to signing prescriptions until later in the dayand this has caused some patients to go to the neighborhood pharmacy only to find the prescription not filled yet.Dr. Johnson carries a tablet PC around with her constantly during the day. She starts her own new note before the patient visit,checks on lab test results in the system, has a nurse enter vitals and meds into the EMR, and then clicks her way through each visitright after seeing the patient, or within the next hour or two during breaks. This includes coding the visit for billing. She does a lot ofcopying and pasting note sections. But because she waits until after the visit to enter any new prescriptions or orders, the CDSSfunctions sometimes cause her to change medications and tests she told the patient she would be ordering. Since the patient oftenhas already left, this causes the staff to have to try to contact the patient later, unless they have the patient’s cell phone number touse right then while the patient is driving home or to work. CMS/Medicare is calling for an audit of her notes since to them they alllook very similar in wording and style, and she seems to be overcoding visits. They suspect fraud but in reality Dr. Johnson is makinginnocent mistakes because she is rushing to finish.Nurses sometimes work for more than one doctor. They cover each other’s shifts. Sometimes a med tech does some nurse duties.The current system has left them confused. They have trouble remembering which doctor likes to document which way. Thephysicians get frustrated when covering for each other because they don’t know if they should use their own style or the otherphysician’s style. The practice manager is frustrated because she still has to keep a transcriptionist on call, though that workerdoesn’t get as much work as before. They haven’t gotten out of paper as much as she thought they would. And they are thinking ofhiring a professional coder.You are an EMR implementation consultant brought in to try to improve the situation. Abandoning the EMR at this point is not anoption. Using knowledge gained in this course, write a 1000-word case analysis and recommendation. Be specific. You might trylisting the problems and addressing them one by one. Consider what we learned from class readings about physician preferencesand workflow in determining how much standardization you would require and what it would be. No references needed.