I am working in the acute rehab at the academic hospital right now. We have a good system, but not great. It is difficult to get PT/OT notes and assessments. From a previous manager of the IT department (I was not a techie, I just told them what was priority and gave them $$), I think a simple code could make things easier.

However, we still have paper records. At a hospital, it is almost impossible to have enough computers to people. As a discharge planner, I still have to keep paper applications to SAR and SNF, and whatnot. Most importantly, I have my little post-it notes with phone numbers and my doodles.

But the medical paper chart has the doctor’s daily round notes (that only he and his residents can read!) and healthcare proxies, and allergies and precautions. The paper chart is really limited. Meds are giving by “cows” with barcodes. It is all good.

I really like your new intro on the side bar and I like how you vacillate between the absurd, sad, educational and funny, etc., and think you have a great blog!!

hey…what’s a girl gotta do to get a golden Llama award? Can ya make the contests any easier? I am only so humorous you know. I can do inane though. Well you don’t miss what you never had. I may covet…but don’t miss the llama… but I’m coveting. I know…time for me to get some sleep!

I’m interested in what you said about “The payment system discourages EMR adoption” – can you elaborate on that?

As Daphne says, there are times when paper records are still necessary: for example, if a patient writes you a letter saying that they may have been exposed to, say, asbestos at work between 2 dates then you need to keep the paper copy in case they need to raise a future legal action against their then employer, but EMR enables much more “joined up medicine”, say when a patient is transferred between consultants at different hospitals.

I’ve seen several specialists in the past year with varying degrees of EMR implementation, and the ones who use it more fluently seem to have much more efficient offices. It cuts down even on the number of times I have to explain a problem I spoke about at a past appointment; with the computer in the exam room, it’s much easier for the doctor to look up his past notes.

Count me as a patient completely sold on this concept. Given the choice, I would go with an office that has fully implemented EMRs, rather than one still paper-based.

Funny you should describe the problem of overdocumentation as a byproduct of the EMR…a coworker and I (we are both coders for a system of PCP’s offices) were just talking about that today. The standards we use to determine a level assigned to a visit come from those in the front of the CPT code book (as I’m sure you know), and not all practitioners understand that; then they get to wondering why we changed their assigned level (it doesn’t matter the direction; some providers get just as miffed or curious about the upcode as the downcode). We’re not just pulling it out of nowhere; it comes from a documented standard suggested by none other than the AMA. Usually once they realize that, then it makes more sense and the process flows more smoothly.

EMRs are far from perfect, mind you, but they sure do help with that age-old problem of having to decipher impossible handwriting (which comes from a lot of individuals, not just the fabled “doctors have terrible penmanship” category). Sometimes they all start to look the same, but we do have a few “older” docs who write much the same way they’d have probably written in a standard record. A couple of them actually give me a laugh now and again with the things they write in their comments at the bottom of the document. I don’t think I could handle standard paper records; I’d get too lost in the boatloads of extra information that I’d have to sort through. (They are what I learned with while still in school; EMRs were not spectacularly common when I started on my educational journey back in 2000 or so.) The downside comes when the system crashes and you have limited to no access to anything. Then you’re out of luck.