On the 5th Day of #HITChristmas we’re excited to feature, a patient advocate Elisa Comer, CPHIMS, CQA, PMP, CGFI.
Tell us a little bit about yourself and your experience with Health IT/EHR.
I’ve worked in HIT since 1996, first in transcription, then EMR auditing and template architecture. In 2005, I was named Tennessee Small Business Person of the Year and traveled to our Capital, where I was appointed National EHR Coordinator for Transcription. In this role, it was my job to move transcription and narrative charting into the EHR, along with re-tooling the workforce to adapt to the new technology. Because of my nursing background, I was often the clinic liaison in technical meetings, adapting technical workflows to fit the way patients were actually seen in the clinic. A diagnosis of severe rheumatoid arthritis cut this assignment short and in 2017, I had to leave the workforce. I now experience EMR technology as a patient and patient advocate for those with chronic illness, and I’m passionate about teaching people how to read their medical records, and that they even need to.
What’s the number 1 thing you’d like EHR and health IT vendors to know as a patient?
“Good enough” is never, ever good enough when it comes to the quality and accuracy of our medical story. Blatant errors, “small” omissions, and difficult-to-read notes can and do have big consequences. After all these years, not charted is still not done.
In what ways do EHRs help patients?
Coordination of Care
I’m a huge proponent of EMR technology, both as a healthcare professional and as a patient. Most of my doctors have access to my records, which saves a tremendous amount of time copying and sending my records to multiple providers. In a moment, they can see my history, current medications, recent labs, etc. Coordination of care has been simplified tremendously. When EHRs are plugged in to a state or regional health information exchange, the benefit is even greater. This kind of technology is what allows me to be seen at a major hospital system 4 hours away without having to wait for records to be copied and sent, which means I can concentrate on being the patient. HUGE win.
Turnaround time on things like results from the lab or scans from the hospital are available much quicker than having to wait several days for information to be sent to my doctors. This real-time availability has prevented numerous delays in my care and saved significant costs by avoiding duplication of services.
Prescriptions that are EMR’d over to the pharmacy are available quickly and I can just pick them up on the way home without having to drop off and pick up later (assuming the medication was clicked in properly, which isn’t always the case). This seems like a small thing, but when you’re sick, it is a huge help.
I can access my records via patient portals, and can also communicate with my physicians and providers with basic questions. This saves countless hours and days over old-time calls and leaving messages, visiting the clinic in person, driving around picking up paper records, waiting for records to come in the mail, etc. The efficiency for the patient in these regards cannot be overstated. As an immunocompromised patient, any time I can handle lesser things via a portal and not have to make a clinic visit eliminates unnecessary exposure to illness, like during flu season or the Covid-19 pandemic, for example. Dealing with insurance is often much quicker, since I can access my records and get the information the insurance representative needs right there on the phone call.
How do EHRs hurt patients?
While EHRs can be a huge benefit to patients, there are issues that do not help us, and often these are quite significant.
The biggest way EHRs hurt patients is the compromised quality that is now accepted in our charted notes. Errors of omission and commission alike often record a different story than what actually happened in an exam, exactly what a family or social history is, etc. Context is of great importance to the patient’s story, but is difficult to assess when clicking single words, linking simple phrases together, or working around computer jargon like ampersands and percent signs. “Old cell” carcinoma is not an acceptable substitute for “oat cell” carcinoma, in spite of the clinic telling you it’s “close enough” or “any doctor will know what we meant.” This is simply unacceptable.
Just as having notes shared amongst providers in real-time is advantageous in many ways, errors have simply become “fast errors.” This means that as errors enter the patient record, they are sent/replicated across all the platforms to which they are attached. In other words, if my PCP makes an error, then it also appears in the information my Rheumatologist, Cardiologist, etc., accesses. Likewise, if I correct it, I must correct it at the source, then also go back to the other providers and correct it there, too. Addended notes have their place, but unless you know an addendum has been made to an encounter, you don’t readily know there was an error in the first place. If the wrong cc physician is chosen and I don’t know it, then my records go to physicians they are not supposed to go to, which is, at the least, a HIPAA breach. This all takes place almost real-time per the computer systems and while it can be corrected, it is after the fact, sometimes much later, and very time-intense. I don’t want to have to oversee this; I just want to be the patient and try to get better.
Lack of Detail/Progression
Another way our notes are compromised is the use of “new note from an old note.” While seemingly helpful, this EHR function is over-used and especially problematic in that the notes don’t accurately describe the progression of a patient’s chronic condition(s). Some insurance providers no longer pay claims when notes are verbatim over several clinic visits and over time. I have personally had notes where the first paragraph stated “patient is ambulating without difficulty” because that was the case for the last two visits. Yet in the physician’s typed paragraph at the end, he noted that I was using my walker that day, which was the case with the current visit. This inaccuracy is confusing and opens the door to adverse insurance determinations, creating considerable extra work for the patient, the clinic staff, and even the physician. Things like excused days from work can also be compromised, since the note gives conflicting information about how the patient was or was not able to ambulate on a given day.
Compromised Time with Clinician
Another way EHRs have hurt patients is that the computer has hijacked our clinic experience. The already limited face-to-face time with our doctor has been significantly decreased even more with the implementation of EHR systems. Our physicians are now the highest paid data entry people on the patient care team, and the computer fatigue they speak of is palpable in the encounter. They are burned out. This isn’t why they went into medicine. It’s a real problem and has been well documented in recent years and is one of the worst unintended consequences of the EHR, in my opinion.
What can be done to improve this?
The best thing to improve this – and I would argue, the only thing – will be for patients (consumers) and payers (insurance companies) to push back and demand better quality and level of detail.
As a former National EHR coordinator for Transcription, how do you see notes being impacted as doctors have mostly moved away from transcription?
Generally speaking, with narrative charting (dictation), the rich detail of the patient encounter told the whole story and put things in full context of what was going on with the patient. This was especially helpful for patients with chronic conditions that progress over time, or those with rare conditions not well known or often seen. Sometimes details about a patient’s home life or social environment were important to the course of disease or treatment decisions/outcomes.
Now that click-based charting and non-reviewed voice recognition is the norm, these details, context and the full patient story are often lost, or are at least compromised and wrought with errors. If an exact word or phrase isn’t on a drop-down list, the usual protocol is to select “the closest one” which may or may not convey the exact message. Sometimes this small substitution really can be of consequence to the patient. Too often, click-mistakes and unedited voice recognition errors are not caught, making their way into the permanent record. Thus, “85% accuracy” has become “good enough.” We would never accept a surgeon with 85% accuracy. For that matter, we’d never accept 85% accuracy on our checking account balance. Yet this is now the norm with our records in many cases. I have seen worse. Much worse, in fact. And more often than not, the patient is none the wiser.
With EMR charting, it is harder to chart by exception, because when thinking of a drop-down list of possibilities, it is impossible to think of all the exceptions one might encounter. One example is an unconventional use of meds. I have erroneously had a diagnosis of “ADD” in my chart because “Provigil” appeared on my medication list. Provigil is a well-known drug for ADD and this is, indeed, its usual use. But in actuality, I have a rare condition, dysautonomia (from Sjogrens), that causes my pulse and BP to bottom out without warning. One of the lesser known uses of Provigil is that it temporarily raises your BP. So for patients with autoimmune disorders like Sjogrens and dysautonomia, we can bypass taking so much prednisone (with all its long-term side effects) by propping up low BPs with something like Provigil instead. Unfortunately, most often click-based medication lists do not have a field to enter/add this level of detail about a medication, so at first glance and without any reason to think otherwise, a doctor would naturally think I had ADD. But this is not the case at all. This kind of missing detail has become acceptable in today’s click-based charting protocols. In reality, I have to be on guard to point out the correct reason I use this medication all the time because the level of detail in the EMR-generated notes just isn’t there.
One of the biggest ways the documentation cycle has changed since moving away from dictation/transcription is the real, palpable problem of computer fatigue for the doctors. They are now the highest paid data entry member of the patient care team. Many doctors do not type fast, so computer entry really slows them down. Physicians frequently report that their workdays increased by several hours when they had to start clicking and inputting their notes instead of speaking/dictating them. When voice recognition protocols can be trained to high levels of accuracy, sometimes this is helpful for quicker reporting by the physicians. But voice rec often lacks a review process, and this is inclined towards errors in the permanent record. Busy specialists are known to “catch up” on their documentation on weekends or in the evenings. It’s no wonder that over time, physicians feel burned out and overloaded by EHR click-based entry versus just speak it and allow those who transcribe it better and faster to assist them. Use of in-clinic scribes is becoming a reasonable way to share the workload in some cases.
If you’re helping a patient understand their medical record, what suggestions would you make to them?
First and foremost, never, ever make the assumption that “my doctor’s office takes care of that for me.” Accuracy in our records requires that we be hands-on with reading our notes, knowing what our illnesses and medications are, and making sure the record is accurate. Many times, it just isn’t. Learn not only how to recognize errors in our records, but know what to do to get them corrected, as well.
What can the health IT community do to help you?
I’ve always thought we missed the quality mark when EHRs were first implemented. Most of the EMR programmers I worked with for many years and across many states did not have experience working with patients. While they were amazingly talented in their sphere of genius, they just didn’t have a vast understanding of the workflow of patient care. For this reason, I think we missed having systems that would lend themselves to documenting with the same level of detail that had proven useful before. Consequently, quality has been re-defined over the years, some for the better and some, not so much.
From a patient’s perspective, the health IT community could help by bringing attention to quality issues and emphasizing how important accuracy is to the patient’s journey. While many steps of the journey take place outside a clinic setting, there’s reliance upon accurate clinical documentation at every juncture. It’s important that the patient encounter notes be accurate, detailed, and timely. The documentation cycle has to be bigger than just eliminating a transcription bill and it’s important to have the C-levels on board with this concept. Clinical documentation must include all pertinent details of the patient’s story, whether or not those details appear in a drop-down list, and it must be accurate, with correct spellings and correct choice of words and phrases. It must also be easily readable, which is never the case when clinic notes have technological special characters like ampersands embedded in the wording. A busy ER physician dealing with a true emergency doesn’t have time to try and decipher code-speak in a patient’s medical history or current medication dosages. These things make a difference, they really do.
All things said, my professional and patient opinion is that EHR technology has always held great promise and definitely has a place in the patient and clinician experience. However, there are parts that must be improved if we are ever to achieve the initial goal, which was to improve patient care with the use of EMR technology. We may be there in some regards, but we are not in others. Engaging the patient is key, and that is most likely done through ongoing education. In the end, the patient doesn’t really care how the information enters the permanent record, so long as it’s correct, detailed, and timely when it gets there.
We still have some work to do, friends.
Be sure to follow all of the 12 Day of #HITChristmas.