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>> Documenting it so that it can be billed appropriately is also crucial. This is literally the only reason why scribes, or pretty much any EMR exist. EMRs ar

>> Documenting it so that it can be billed appropriately is also crucial. This is literally the only reason why scribes, or pretty much any EMR exist. EMRs are an accounting tool. To avoid "down coding" and legal exposure . Plain and simple. There's a reason that doctors would not adopt EMRs for the longest time (at least in the US, don't know other nations) until actual legislation was passed to force them to do so, else get shut out of Medicare. The EMR, and therefore most note-taking, is not as value add to the patient, or doctor. Its just the only way the doctor will be paid. The EMR of the future will not have an encounter in a computer. It will be computerless. AI will be acting like zapier between payor APIs, doctor's invoicing, and the patient's chart.

karencarits 2y ago
> The EMR, and therefore most note-taking, is not as value add to the patient, or doctor. Its just the only way the doctor will be paid. I don't think this is true as proper note-taking and documentation is required by law in many countries where the doctor is not paid per patient/procedure
- IG_Semmelweiss 2y ago
  OK, but you need to clarify your statement. As you said, >>> note taking and documentation is required by law. So then, the EMR not a value add, which is also what I wrote. It just so happens that in the US the primary reason is to get paid, and its also why some doctors still eke out a living without an EMR (but still with some kind of paper medical files)
  - robrenaud 2y ago
    Do EMRs improve the standard of care?
    - adzm 2y ago
      Absolutely. They can allow providers to easily track their adherence to Patient Quality measures which directly affects their income.
      - IG_Semmelweiss 2y ago
        The question is whether they improve the standard of care. Quality measures produce numbers so bean-counters are satisfied at CMS. For example: Before i was not submitting any quality measures, but my patient satisfaction was sky high, and i had the lowest complications for years. Now i report quality measures, but as a result of documentation requisites and reporting requirements, i have less time to see patients , and therefore make more mistakes. My quality measures are good because I'm talking to patients about quitting smoking and getting leaner - but i was already doing that previously. Now objectively, since I now have less time due to EMR requisites, my patients are worse off than before and it shows with slightly more complications my patient's aren't as happy as their waiting times are longer (and getting worse too).
    - j45 2y ago
      Big time. In some cases where hospitals do paper charting, it can be mis charted. or, there can be issues with not recording medication as being given or not, and the patient can miss their dose because a nurse thinks it was given. There is some cases where such confusion is tolerated depending on the patient.
      - IG_Semmelweiss 2y ago
        >>> or, there can be issues with not recording medication as being given or not, and the patient can miss their dose because a nurse thinks it was given. Partially true. First, there's no need to record anything in any EMR, this is a big misunderstanding. The act of sending the script is recording it itself. There's no need to do data entry in EMR. You can test this by simply attempting to send eScripts outside of the EMR. PBM systems like surescripts will alert the provider as he's prescribing in any other 3rd party system of any problems (multiple scripts of same meds, reactions, etc). Even a paper script needs to be adjudicated via PBM by the pharmacy, which means there's a PBM record already the moment that script is created and picked up. That's how most doctors and pharmacies know whether pts are picking up their meds. Now if a doctor is fully on paper based then you do have a problem because there's no feedback to a paper record IF the doctor is failing to log into the PBM system to check for drugs dispensed. In this case, the EMR may appear superior on this front, but it also introduces its own set of problems, such as a very common one - patients missing their scripts because the pharmacy is out of meds, causing multiple scripts being sent and back and forths with busy doctors. This is never a problem with a paper script. Perhaps one of the very few value adds is turning the MD scribble into something legible, but that's something that can easily be solved without any click, or an EMR in the middle .
        j45 2y ago
        > First, there's no need to record anything in any EMR, this is a big misunderstanding. The act of sending the script is recording it itself. There's no need to do data entry in EMR. Not quite. Hospital EMRs now have barcoding and scanning, for timed doses being delivered an to make sure they were - saw it first hand in the past year. This is a shadow working culture issue, not a technical one. Hospital workplace cultures can be quite toxic, and that plays out varying degrees of horrible for certain segments of the population 60 percent of the time, every time. In hospitals, prescriptions are administered usually by a nurse. Since it's a problem that can be casually looked away from because it doesn't impact one group, it can be downplayed.
- j45 2y ago
  Digital records are valuable for health in several cases, for example, when the patient needs or wants all their records.
swader999 2y ago
My wife is a vet where the legal penalties are far less but she contends that proper medical records are critical, one of her most important asks of colleagues.
- IG_Semmelweiss 2y ago
  A medical record can be paper or electronic. The key question, is whether that record is proper or not. Most EMRs have copy pastes of staff paid $15 per hour and of doctors completing e-notes in under 3 mins for each pt the night after the encounter happened. That's hardly proper records.
lotsofpulp 2y ago
> The EMR, and therefore most note-taking, is not as value add to the patient Since patient’s medical histories are relevant to treating medical issues, having quick access to accurate medical histories is a value add for the patient. Just the simple fact a pharmacist does not have to decipher chicken scratch to get people the right medicine is a value add for patients. My family chooses to frequent doctor groups that integrate with the local hospitals’ EMRs because it allows the hospital doctors immediate access to all the information they need in the event of an emergency.
- IG_Semmelweiss 2y ago
  That can be easily solved without an EMR. In fact, that's a good AI use case
  - pixl97 2y ago
    This doesn't make any sense... an AI is going to be reading the EMRs.
    - IG_Semmelweiss 2y ago
      Sorry, I'm talking about traditional EMR. But you are correct, 'record' will be a storage service with no front end required inputs from the doctor. That's the point. Inputs and outputs without a keyboard or mouse. Just natural language. In effect, EMRs would become voice-enabled AI chatbots.
xyst 2y ago
It’s not the sole reason but given that billing is based on it (ICD codes). I can see your point. I remember the bean counters from the hospital going over with scribes and doctors on how to “properly” document all the necessary elements to bill for a procedure. All of it was very very boring. “We can bill for ED physician prelim reads of radiology studies but it needs to have at least 3 or more findings documented. “ So let’s say a an ed physician orders a chest xray to r/o pneumonia vs bronchitis. Have to document in chart something like: “3 view chest xray; no infiltrates, no pleural effusion, no pneumothorax; received by X doctor” In reality, most doctors would just put “reviewed 3v cxr, no infiltrates”. No need to document negative findings that contribute nothing. Prior to EMRs, hand written notes and charts were absolutely god awful to read. Physician and nurse short hand is not standardized. Plus some doctors handwriting is just atrocious. EMRs helped standardize communication between multiple parties (both medical and non-medical). Like others have mentioned, it could have been a way to track standards of care across multiple hospitals or across the US. Unfortunately with the gold rush to get a product out there, all we got was 9-10 different proprietary EMR systems that do not have interoperability. CT scan performed in Virginia and needs to get reviewed by doctor in California? The hardcopy of the images uses some proprietary viewer that is only accessible within the same system the Virginia hospital used. I remember a few cases of this when we had transfers from out of state. Either hospital physician gets their own additional scan and official read or waits for physical images from other hospital to view. I think in a CT this can be hundreds of images/slices. (Don’t quote me on this, this was a decade ago lol)
j45 2y ago
If a doctor can verbally get all notes, they will forget to write less, or ensure follow ups, referalls, etc go.

karencarits 2y ago

> The EMR, and therefore most note-taking, is not as value add to the patient, or doctor. Its just the only way the doctor will be paid. I don't think this is true as proper note-taking and documentation is required by law in many countries where the doctor is not paid per patient/procedure

IG_Semmelweiss 2y ago
OK, but you need to clarify your statement. As you said, >>> note taking and documentation is required by law. So then, the EMR not a value add, which is also what I wrote. It just so happens that in the US the primary reason is to get paid, and its also why some doctors still eke out a living without an EMR (but still with some kind of paper medical files)
- robrenaud 2y ago
  Do EMRs improve the standard of care?
  - adzm 2y ago
    Absolutely. They can allow providers to easily track their adherence to Patient Quality measures which directly affects their income.
    - IG_Semmelweiss 2y ago
      The question is whether they improve the standard of care. Quality measures produce numbers so bean-counters are satisfied at CMS. For example: Before i was not submitting any quality measures, but my patient satisfaction was sky high, and i had the lowest complications for years. Now i report quality measures, but as a result of documentation requisites and reporting requirements, i have less time to see patients , and therefore make more mistakes. My quality measures are good because I'm talking to patients about quitting smoking and getting leaner - but i was already doing that previously. Now objectively, since I now have less time due to EMR requisites, my patients are worse off than before and it shows with slightly more complications my patient's aren't as happy as their waiting times are longer (and getting worse too).
  - j45 2y ago
    Big time. In some cases where hospitals do paper charting, it can be mis charted. or, there can be issues with not recording medication as being given or not, and the patient can miss their dose because a nurse thinks it was given. There is some cases where such confusion is tolerated depending on the patient.
    - IG_Semmelweiss 2y ago
      >>> or, there can be issues with not recording medication as being given or not, and the patient can miss their dose because a nurse thinks it was given. Partially true. First, there's no need to record anything in any EMR, this is a big misunderstanding. The act of sending the script is recording it itself. There's no need to do data entry in EMR. You can test this by simply attempting to send eScripts outside of the EMR. PBM systems like surescripts will alert the provider as he's prescribing in any other 3rd party system of any problems (multiple scripts of same meds, reactions, etc). Even a paper script needs to be adjudicated via PBM by the pharmacy, which means there's a PBM record already the moment that script is created and picked up. That's how most doctors and pharmacies know whether pts are picking up their meds. Now if a doctor is fully on paper based then you do have a problem because there's no feedback to a paper record IF the doctor is failing to log into the PBM system to check for drugs dispensed. In this case, the EMR may appear superior on this front, but it also introduces its own set of problems, such as a very common one - patients missing their scripts because the pharmacy is out of meds, causing multiple scripts being sent and back and forths with busy doctors. This is never a problem with a paper script. Perhaps one of the very few value adds is turning the MD scribble into something legible, but that's something that can easily be solved without any click, or an EMR in the middle .
      - j45 2y ago
        > First, there's no need to record anything in any EMR, this is a big misunderstanding. The act of sending the script is recording it itself. There's no need to do data entry in EMR. Not quite. Hospital EMRs now have barcoding and scanning, for timed doses being delivered an to make sure they were - saw it first hand in the past year. This is a shadow working culture issue, not a technical one. Hospital workplace cultures can be quite toxic, and that plays out varying degrees of horrible for certain segments of the population 60 percent of the time, every time. In hospitals, prescriptions are administered usually by a nurse. Since it's a problem that can be casually looked away from because it doesn't impact one group, it can be downplayed.
j45 2y ago
Digital records are valuable for health in several cases, for example, when the patient needs or wants all their records.

swader999 2y ago

My wife is a vet where the legal penalties are far less but she contends that proper medical records are critical, one of her most important asks of colleagues.

IG_Semmelweiss 2y ago
A medical record can be paper or electronic. The key question, is whether that record is proper or not. Most EMRs have copy pastes of staff paid $15 per hour and of doctors completing e-notes in under 3 mins for each pt the night after the encounter happened. That's hardly proper records.

lotsofpulp 2y ago

> The EMR, and therefore most note-taking, is not as value add to the patient Since patient’s medical histories are relevant to treating medical issues, having quick access to accurate medical histories is a value add for the patient. Just the simple fact a pharmacist does not have to decipher chicken scratch to get people the right medicine is a value add for patients. My family chooses to frequent doctor groups that integrate with the local hospitals’ EMRs because it allows the hospital doctors immediate access to all the information they need in the event of an emergency.

IG_Semmelweiss 2y ago
That can be easily solved without an EMR. In fact, that's a good AI use case
- pixl97 2y ago
  This doesn't make any sense... an AI is going to be reading the EMRs.
  - IG_Semmelweiss 2y ago
    Sorry, I'm talking about traditional EMR. But you are correct, 'record' will be a storage service with no front end required inputs from the doctor. That's the point. Inputs and outputs without a keyboard or mouse. Just natural language. In effect, EMRs would become voice-enabled AI chatbots.

xyst 2y ago

It’s not the sole reason but given that billing is based on it (ICD codes). I can see your point. I remember the bean counters from the hospital going over with scribes and doctors on how to “properly” document all the necessary elements to bill for a procedure. All of it was very very boring. “We can bill for ED physician prelim reads of radiology studies but it needs to have at least 3 or more findings documented. “ So let’s say a an ed physician orders a chest xray to r/o pneumonia vs bronchitis. Have to document in chart something like: “3 view chest xray; no infiltrates, no pleural effusion, no pneumothorax; received by X doctor” In reality, most doctors would just put “reviewed 3v cxr, no infiltrates”. No need to document negative findings that contribute nothing. Prior to EMRs, hand written notes and charts were absolutely god awful to read. Physician and nurse short hand is not standardized. Plus some doctors handwriting is just atrocious. EMRs helped standardize communication between multiple parties (both medical and non-medical). Like others have mentioned, it could have been a way to track standards of care across multiple hospitals or across the US. Unfortunately with the gold rush to get a product out there, all we got was 9-10 different proprietary EMR systems that do not have interoperability. CT scan performed in Virginia and needs to get reviewed by doctor in California? The hardcopy of the images uses some proprietary viewer that is only accessible within the same system the Virginia hospital used. I remember a few cases of this when we had transfers from out of state. Either hospital physician gets their own additional scan and official read or waits for physical images from other hospital to view. I think in a CT this can be hundreds of images/slices. (Don’t quote me on this, this was a decade ago lol)

j45 2y ago

If a doctor can verbally get all notes, they will forget to write less, or ensure follow ups, referalls, etc go.