EMR Documentation by Exception or Veracity

If you’ve been reading me for a while, you know that I have a few hundred draft posts (basically ideas) for future posts. However, the news about meaningful use is coming out so quickly that it’s not that often that I have to go back and use those draft posts. I probably should do it more. Well, when I was working on my soon to be released e-Book on EMR selection, I ran across this comment about two different ways of documenting in an EMR. It’s written by Matt Chase from Medtuity and likely was originally posted on EMRUpdate (sadly, I don’t have the original link).

I’m a total Matt Chase fan boy, and this type of information is what makes him so good. Plus, if you’ve ever received a 10 page note with about 1 small paragraph or relevant information, then you’ll find this information VERY interesting.

There are two methods of documenting with templates: documentation by exception, or DBE, where the template is pre-answered, and documenation by veracity (where you actually gather a history and examine the pt before documenting).

The first (documentation by exception) usually puts into the chart a huge number of normal items and the physician’s duty is to change what does not apply. The “change what does not apply” becomes too burdensome because there is so much fluff on each patient, that it is simply easier to forego the editing. This contributes to the not so unusual findings of “normal clinical *** exam” in a 7 year old boy and “normal descended testes bilaterally” in a 12 yr old girl. Think of it as every 80-yr old male appears on paper identical to every 20 yr old, strapping young man– no abnormalities.

The VA is probably using documentation by exception. The easy way to tell if a system uses DOE is by simply printing an encounter. If it exceeds 1-2 pages, it’s probably DOE.

In contrast, the better method of documenting is for the EMR to present a template with all of the relevant findings, both normal and abnormal but allow the physician to click the findings. For example, a sore throat encounter would have all those things important to a sore throat, including history of fever, difficulty swallowing……through a good neck and throat exam. You would not expect it to document a *** exam, digital rectal exam, or exam of the genetalia. IT’S A SORE THROAT! The documentation would be relevant and short.

With the proper mix of “input controls”, such as checkboxes, right-left-bilateral, positive/negative, multiple choice text controls, calendars, number control, and dozens of other types, it is possible to rapidly enter truthful information. Many EMR’s have only several types of controls (either checked or unchecked), making it easier for the designer of the system to simply put in paragraphs of text (hence the DBE).

Obviously, my disdain for padding the chart with meaningless information is a strong indicator that at Medtuity, we provide a system where the physician clicks to enter truthful information. We take the step of allowing information to be entered quickly.

The local hospital’s emergency department uses one of the “big boy” EMRs that performs documentation by exception. For example, every ankle sprain has a full neurological exam placed in the chart, by default. It does not matter that few ankle sprains receive a full neuro exam. For EMRs designed for DOE, they usually generates a high billing code because including 30 normal findins in the chart is easier than documenting a couple of abnormals.

Selling our product locally always generates the same question: “My documentation won’t look like the ER’s, will it?”. Nobody wants a multi-page report of meaningless normal findings.

One reason, I believe, that there is a lower penetration of EMRs among specialists is this problem of padding a chart with a single click. The charts produced by specialists are actually read by the referring primary care physician. When anticipating a colleague reading the chart, they may hold themselves to a higher standard.

On the other hand, we feel that the scores of questions that are asked by the specialists again and again, with every patient, should be easily responded to with just a few clicks to set many responses to negative. For example, a *** surgeon will ask about *** self-exam findings including lumps, nipple discharge, skin dimpling…through weight loss, bone pain, etc, etc, many times a day. Most of these are negative.

Our profession may blame the insurers and Federal Govt for documentation by exception, but the reality is, it is a design defect. It is very easy to design an EMR for DOE. It is much harder to design an EMR that allows pertinent positives and negatives to be quickly entered.

Probably the easiest method for determining whether an EMR depends on DBE is to ask how many control types they have for entering data. We have over 40 in MedtuityEMR, and counting. I simply cannot fathom how EMRs can get along with just a couple, IMHO.

I asked for a demo of a common peds and family practice complaint (otitis) from “big boy” EMR user. Perhaps this problem has been remedied, but for such a common complaint, there was no means in his template to show:
ear canal occluded with cerumen
bulging TM
erythematous TM
tympannostomy tube present
perforation of TM
location of perforation
retraction of TM
normal TM
scarring of TM
TM motion on pneumotoscopy
………and about 10 other findings that you may wish to show, whether positive or negative) on your ear exam. He couldn’t even click right or left but had to rely on “the affected side”.

There was but one selection available for ear exam (normal/abnormal). That was perhaps two years ago and things may have changed.

So if you are shopping for an EMR and this matters, just ask the demo’er to show you a bunch of abnormal tympannic findings for a screaming 4 yr old. That will tell lots.

Matt Chase
“Practice medicine, not paperwork” ™

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


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