Electronic Medical Records Inpatient Practice

Are Verbal Orders A Patient Safety Concern?

Hospitals have a love-hate relationship with verbal orders. On the one hand, they can expedite care to the patient and can save physicians time. On the other hand, they can increase medical errors. Some groups believe strongly that the goal should be to have zero verbal orders whereas others believe that there should be no barriers to verbal orders. Electronic medical records have reduced the use of verbal orders in some situations but promoted the use of verbal orders in others.

The Joint Commission, the Leapfrog Group, the Institute of Medicine, and the Institute for Safe Medical Practice have all called for reducing or eliminating verbal orders. Nursing groups often see verbal orders as dangerous because of the risk that a verbal order error will place nurses in a position of liability. The Health Systems Management Society that determines best practices in hospital medical record keeping has set a goal that verbal orders should be < 10% of a hospital’s total inpatient orders and < 5% of a hospital’s total outpatient orders.  The literature is rife with anecdotes of the nurse who thought a doctor said to give a patient 10 mg of Viagra when the doctor actually said to give 10 mg of Allegra. The reality is that verbal orders can both improve patient safety and worsen patient safety.

Electronic medical records have reduced verbal orders

Much of the literature on verbal orders is from a pre-electronic medical record era. 15 years ago, most hospital orders were written in the patient’s paper chart that was kept in a nursing station. For a physician to place an order, that physician had to go to the nursing station hand write the order. If the doctor was out of the hospital or was on a different floor of the hospital, then entering an order was not possible and verbal orders proliferated. A bad phone connection, a doctor with a foreign accent, or a lot of background noise in the nursing station helped to foster mistakes. Although physicians had to eventually sign those orders, signing often didn’t happen until weeks after the patient was discharged when the patient’s chart was flagged by the medical record department as containing an unsigned order. Every physician who practiced in the 1990’s can remember weekly trips to the medical record department where each physician would have a stack of discharged patient charts requiring signatures.

Pharmacy orders were a particular problem. In the by-gone era of the physician’s prescription pad, a hand written prescription was given to patients at the time of an office visit or when being discharged from the hospital. But if that patient called in with an acute illness or needed a prescription refill, then the doctor had to call the pharmacy to give the pharmacist a verbal order for a medication. On nights that I was on-call, I would almost always have to phone in a verbal prescription to a pharmacy for a patient needing an antibiotic or an asthma inhaler; the options were either a hand-written prescription or a verbal order.

With the advent of electronic medical records, a physician no longer had to be physically in a specific nursing station to place an order. Doctors could now access the patient’s chart from a computer located anywhere and can even place orders from an app on their phone. I have not hand-written a prescription on a prescription pad in years. Even when I am on call, I find it easier and faster to send in a prescription by computer or by an app on my phone than to call a pharmacy (and be put on hold for several minutes). It is now easier than ever before to place an order electronically and this has reduced the need for verbal orders.

When verbal orders are a good thing

There are times when a physician simply cannot safely place an order in the electronic medical record. For example, the surgeon who is scrubbed in the middle of an operation cannot break scrub to place an order for the nurse to give the patient a fluid bolus. The family physician who is at a restaurant having dinner and gets a call from a patient with bronchitis cannot easily walk away from the restaurant, drive home, get on a computer to access the electronic medical record, and then send an electronic order for an antibiotic to the patient’s pharmacy. When a physician is driving to work in the morning is called from the ICU about a patient who is seizing, that patient needs to receive a dose of lorazepam immediately and not 15 minutes later when the doctor has access to a computer to place the order.

The reality is that most hospital locations have to use verbal orders some of the time in order to ensure timely care of patients. But there are some areas where a higher percentage of verbal orders (> 10% of the total) is more necessary than other areas:

  1. Operating rooms
  2. Intensive care units
  3. Cardiac catheterization labs
  4. Endoscopy labs
  5. Dialysis units
  6. Cardiac echo labs
  7. Emergency departments
  8. Radiology areas
  9. Patient emergencies anywhere in the hospital

When verbal orders are a bad thing

Although electronic medical records are ubiquitous today, most hospitals have only adopted them in the past 10 years. Consequently, there are many physicians who are still unfamiliar with the use of electronic medical records. Probably every hospital in the country has that doctor who still has not figured out how to place an order in the electronic medical record and gives all of his/her orders as verbal orders to a nurse. As younger, more computer literate physicians replace older, less computer literate physicians, this will be less of a problem in the future.

It can take time for a physician to enter orders in the computer and having someone else do it for you can improve your efficiency and allow you to spend more time actually talking to the patient. Consequently, many physicians like having a nurse that they can dictate orders to follow them around in the clinic or during hospital rounds, entering those orders into the computer as the doctor goes from one room to the next. This is an expensive use of a nurse and most physicians in small private group practices realize that it is financially untenable. However, hospitals have to court certain specialties, particularly surgical specialties, to keep them from moving their practice to another hospital in town. So, hospitals are often willing to provide an order scribe to the surgeon who brings a lot of high value surgical procedures to the hospital’s operating room. They know that they stand to make more from the surgeries than they will lose in the cost of the nurse to do order entry. The hospital can stand to ignore the hospitalist who says “Let me give verbal orders or I will leave” but cannot ignore the joint replacement surgeon or neurosurgeon who says the same thing.

There are situations when orders are generally not emergent and the risk of a medical error from an incorrect verbal order is just too great:

  1. Chemotherapy orders
  2. “Do not resuscitate” orders
  3. Orders for narcotics when the nurse/pharmacist cannot confirm that the person calling in the order is actually the doctor

Minimizing the risks of verbal orders

Given that the use of verbal orders is beneficial to patient care in certain situations and essential to patient care in others, complete elimination of verbal orders is neither practical nor possible. However, there are certain steps that the hospital can take to reduce the chances of verbal order errors:

  1. Use “read-back” of the order by the nurse or pharmacist so that the physician can confirm that what he/she actually said was what the nurse or pharmacist heard.
  2. Avoid using abbreviations. “QID” can sound too much like “QD” on the phone. Saying “K” for potassium can be confused for vitamin K.
  3. Beware of “sound alike” medications. It is easy to mistake “Tramadol” for “Toradol” or “clonidine” for “Klonopin”.
  4. Keep the noise down. A lot of people talking loudly in the nursing station makes it harder for the nurse taking a verbal order to hear that order correctly.
  5. Beware of accents. Regional American accents, foreign accents, and speech impediments can make it difficult for the nurse or pharmacist to understand the doctor accurately.
  6. If it doesn’t make sense, confirm it. If the ER physician tells a nurse to do a pregnancy test on the patient in bay 5 and the nurse walks in to find that the patient in bay 5 is a 70-year old named Joesph Smith, then it is best to double check with the doctor before asking for a urine sample.

Despite what some would have us believe, verbal orders are not inherently evil. However, they can create vulnerability from both a patient safety and medical-legal standpoint. Hospitals do need to regularly monitor for judicious use of verbal orders.

February 22, 2020

Electronic Medical Records

The Problem With The Problem List: when electronic medical records go rogue

Prior to the 1960’s, medical records were largely illegible, unorganized, and non-uniform. It was difficult for a doctor to keep track of his/her own patient’s histories and nearly impossible for a doctor to tell what was going on with a patient by reading another doctor’s notes. Enter Lawrence Weed, MD, a Professor of Medicine at the University of Vermont who invented the S.O.A.P note and taught generations of medical students to organize their hospital notes into the 4 sections of Subjective, Objective, Assessment, and Plan. He was also the father and champion of the  Problem-Based Medical Record, a way of organizing and filtering the various signs, symptoms, and diagnoses that a patient has in order to coordinate the diagnostic effort and to provide optimal longitudinal care of that patient.

When the Center for Medicare and Medicaid Services (CMS) wanted to encourage the widespread use of electronic medical records, it rolled out the “meaningful use” program as part of the HITECH Act of 2009. Physicians who adopted electronic medical records with several provisions were eligible for incentives of up to $44,000 to help offset the cost of purchasing and implementing an electronic medical record. Those electronic medical records had to:

  • Use computerized order entry for medication orders.
  • Implement drug-drug, drug-allergy checks.
  • Generate and transmit permissible prescriptions electronically.
  • Record demographics.
  • Maintain an up-to-date problem list of current and active diagnoses.
  • Maintain active medication list.
  • Maintain active medication allergy list.
  • Record and chart changes in vital signs.
  • Record smoking status for patients 13 years old or older.
  • Implement one clinical decision support rule.
  • Report ambulatory quality measures to CMS or the States.
  • Provide patients with an electronic copy of their health information upon request.
  • Provide clinical summaries to patients for each office visit.
  • Capability to exchange key clinical information electronically among providers and patient authorized entities.
  • Protect electronic health information (privacy & security)

And so, the problem list because a necessary part of every electronic medical record program in the country. On the surface, this sounds like a great idea – an easy way for multiple physicians using the same patient’s chart to quickly and easily see what is going on with that patient. However, the problem list rapidly morphed into a monstrous of list of often redundant words that became unusable for their originally intended purpose. So what happened to the innocent problem list?

Electronic medical record (EMR) companies designed the EMR so that the problem list was the central repository for all lists used in the chart. Elements of the past medical history fed into the problem list as did billing diagnoses, admitting diagnoses, and discharge diagnoses. Similarly, the problem list could be used to select the billing diagnoses, admitting diagnoses, and discharge diagnoses. Because the problem list was used to assign the billing diagnoses, all 69,000 diagnoses in ICD-10 had to be selectable in the problem list. And thus all of the weird and obscure ICD-10 codes suddenly became available to add to the problem list (such as V91.07XA: Burn due to water skis on fire, initial encounter).

What Is A Problem, Anyway?

Medical diagnoses are clearly problems. But there are other elements that are not so clear. Should the family history be included in the problem list? What about the social history? Should the patient’s list of surgeries be added to the problem list? What about non-specific symptoms – should the patient with I50.23 (Chronic systolic heart failure) also have orthopnea (R06.1), history of cardiomegaly (Z86.09), and pedal edema (R60.0) on the problem list?

Duplicate Problems

Each physician who sees a patient might use a different word to describe the same thing and this led to multiple duplicate symptoms on patient problem lists. For example, if a patient with breathlessness gets admitted to the hospital, the emergency room physician might add add the ICD-10 code “R06.00: Dyspnea“, the hospitalist might use “R06.02: Shortness of breath“, and the cardiologist might use “R06.09: Dyspnea on exertion“. By the end of the day, the patient’s problem list will include all three symptoms: dyspnea, shortness of breath, and dyspnea on exertion.

Multiple Layers Of Specificity

Similar to duplicate problems, many diseases can have many different ICD-10 codes for different degrees of specificity of that particular problem. And so “type 2 diabetes” can have a general code and also have many different subcodes, each of which gets its own place on the problem list. For the patient with diabetes who is seeing a family physician, a nephrologist, a cardiologist, an ophthalmologist, and a vascular surgeon, there can be 15-20 different diabetes-related problems on the problem list.

Immortal Problems

Unless someone actively cleans up the problem list, then signs, symptoms, and diagnoses that have resolved can stay on the problem list, causing further clutter. So, Right arm bruise, initial encounter (S40.021A) from an office visit in 2011 persists in perpetuity with Runny nose (R09.89) from an office visit in 2015. Similarly, the patient who had Hyponatremia (E87.1) during an office visit in June and then had Hypernatremia (E87.0) in July can end up with both hyponatremia and hypernatremia on their problem list. Old diseases don’t go away, they just stay around forever on the problem list.

Whose Problem Is It?

Most would agree that the primary care physician should be permitted to add problems to the problem list. But what about the specialist, the emergency room physician, or the hospitalist? Should advanced practice providers such as nurse practitioners, physician assistants, nurse anesthetists, or midwives be allowed to edit the problem list? What about nurses, pharmacists, psychologists, and dietitians? There is no universal agreement about who the stewards of the problem list should be.

Don’t Touch My Problem

Many physicians are very possessive about their additions to the problem list and can get angry if another physician deletes one of their problems without talking to them. So, the patient who was rude to the office staff at the surgeon’s office might have gotten Negative attitude (F60.2) added to the problem list; when the same patient was a delight to the staff in the endocrinologist’s office, the endocrinologist might have deleted F60.2 from the problem list and then the surgeon later gets mad because he wanted that reminder to the staff that the patient was a handful during the last office visit.

Forcing Review Of The Problem List

For many electronic medical records, an outpatient visit cannot be closed until the physician attests that he/she has reviewed the problem list. Typically, an alert box will pop up when trying to close the encounter reminding the physician to review the problem list. By that time, the patient has left the office and the physician just wants to get done with the day’s charting so the physician will typically scroll down to the bottom of the problem list and click “problem list reviewed”, without actually looking at the problem list. Problem list fatigue is just as much of a challenge as alert fatigue in our offices and hospitals.

More Is Less

In the spirit of Dr. Weed, some physicians will organize their progress note in the electronic medical record by importing the patient’s entire problem list into their daily office note. This can result in progress notes that are the length of a small novel making the note unnavigable to any reader and making it more difficult for other physicians to figure out what the author of the note was actually trying to say.

Too Many Problems

Every physician who sees a patient adds her/his problems to the problem list. When I see a patient whose primary care physician and other specialist physicians use a different EMR than I do, I am the only person adding to the problem list and so that problem list is small, relevant to my practice, and manageable. However, the more physicians using a common EMR a patient sees, the longer the problem list becomes. List of 30, 40, or 50 problems are not uncommon for patients with several chronic medical problems seeing multiple specialists or for patients with several hospitalizations.

Erroneous Problems

Errors in the problem list are rampant. For example, a patient fills out a pre-visit past medical history form and checks the review of systems box for “impotence”. The nurse reviews the form and transcribes the checked boxes into the past medical history and accidentally types the first 4 letters as “impr” rather than “impo”. The first diagnosis that comes up under “impr” is imprisonment and so it gets entered into the past medical history that then feeds into the problem list and now “imprisonment” shows up on the patient’s problem list. There are a myriad number of ways that erroneous problems find their way into the problem list and once they are there, they often stay there indefinitely.

High Maintenance Costs

The currency of work effort in ambulatory medicine is the number of mouse clicks necessary to perform any given task. A typical office visit lasts about 15 minutes and there is a lot of things that have to be done in those 15 minutes. Reviewing and editing the problem list costs time and mouse clicks and usually falls down to the bottom of the priority list of things to accomplish during those 15 minutes. Spending an extra 30 seconds per patient to truly review and update the problem list means that over the course of the day, that doctor will see one less patient than he/she otherwise would have seen. One solution that has been suggested is to partner with the patient so that the patient reviews the problem list to help identify resolved or erroneous problems. However, trying to explain what “suprascapular entrapment neuropathy of left side” means to the patient with a sore shoulder can often add 2 minutes to that office encounter.

“Need for…” Diagnoses

Some tests and vaccinations cannot be ordered unless they are associated with a “need for” diagnosis. For example, if you are going to order a flu shot, you have to use the diagnosis of “Need for influenza vaccine” (Z23). Some insurance companies will not pay for a bone density study unless the order is accompanied by the diagnosis of “At risk for osteoporosis” (Z91.89). If you want to see if a patient could have lead poisoning, you need to include “Need for lead screening” (Z13.88). These diagnosis codes often find their way into the problem list and do not add anything to the long-term management of that patient.

Diagnoses Required For Ordering Tests

Similar to the “need for…” diagnoses, many tests cannot be ordered unless the physician uses a specific ICD-10 code or one of a group of codes. These are so-called “allowable codes”. Many electronic medical records will present an alert box if a non-allowable diagnosis code is associated with an ordered test, such as a glucose level or a cardiac echo. The physician will then either keep adding diagnoses to the diagnosis list until she/he comes up with a diagnosis code that the insurance will accept or they will scroll through the list of allowable diagnoses in the alert box and pick a diagnosis code that is covered, whether or not it perfectly matches the real indication for that test. These diagnoses are necessary for the physician to order the test but may be irrelevant to the longterm management of that patient; nevertheless, the codes often end up on the problem list permanently. Physicians hate the alert boxes – they cost mouse clicks and time. Consequently, physicians, like Pavlov’s dogs, undergo operant conditioning and to avoid those alert boxes, they find a diagnosis that insurance companies accept for any given test and always use that diagnosis whenever they order that test. Thus, there are legions of physicians who always use “Other forms of dyspnea” (R06.09) for every cardiac echo that they order because they know that diagnosis works.

When used right, the problem list is a great tool for patient management. But a number of unintended consequences of electronic medical records have resulted in problem list monstrosities that are often irrelevant or a hinderance to medical care. As physicians, we are the main users of the problem list and it is up to us to truly make “meaningful use” of the problem list. We have met the problem of the problem list and the problem is us.

October 8, 2019

Electronic Medical Records

Why Your Electronic Medical Record Upgrade Feels Like A Downgrade

All software undergoes periodic upgrades. This may happen every few years (think Windows or the Macintosh operating systems) or every few months (think Microsoft Word and Powerpoint). Electronic medical records are no different. Sometimes, software upgrades are for improved security, sometimes for better user-friendliness, and sometimes to provide additional features. But whenever they happen, they cause temporary disruption in user efficiency.

Every few years, the grocery store that I shop at re-organizes all of the aisles and all of a sudden, the cans of tomato sauce is where the paper towels used to be and the bacon is where the produce used to be. For a couple of weeks after the re-organization, the manager will post employees throughout the store to help customers find the new location of all of the stuff that they came there to buy. Every time they do this, it feels like my world has been turned upside down, I get angry with the store, and I swear that I’m going to start taking my business to a different grocer down the street. And then after a few months, I’ve figured out how to navigate the new aisle configuration and life is back to normal again.

The same thing happens with electronic medical records. When there is a major upgrade, it immediately becomes hard to navigate the system: orders have to be entered differently, progress notes are organized differently, and a lot of the features that you used to use regularly are seemingly nowhere to be found. All of a sudden, your 15 minute patient encounters are taking 20 minutes and your frustration mounts exponentially. That is the moment that you think that the EMR upgrade was really a downgrade.

Eventually, just like at my grocery store, you get used to the new version of the electronic medical record and life goes back to normal again. But one of the things that is unique about electronic medical records is that doctors don’t have a choice in using them. If you can’t stand the re-organized grocery store aisles, you can take your grocery business to a different store. If you don’t like the new model of the Toyota Camry, you can keep your old one or buy a Honda Accord instead. But with your EMR, you have no alternative, you have to use the new version.

I think that is what makes EMR upgrades so unique – that we have no control. As physicians, we can’t just switch our individual practice to a different EMR and we can’t just decide to individually opt-out of the new version. We have to use the new version and there is no going back. So, what can we do?

For the electronic medical record designers:

  1. Resist software changes that are done simply for change sake. EMRs are not like fashions – with clothing, new styles come out every year to attract new customers and sell more clothes. EMRs are totally different, hospitals generally stick with the same EMR that they have been using and don’t change EMRs every year based on the newest style. If the EMR upgrade was done simply because the new software programmer at the EMR company needed something to do, then it is a downgrade.
  2. Upgrades should prioritize reduced numbers of keystrokes and mouse clicks to perform tasks. Every keystroke adds time and opportunity for data entry errors. If the EMR used to require 10 mouse clicks to order a chest x-ray and with the upgrade it now takes 13 mouse clicks, then it is a downgrade.
  3. Navigation in the EMR windows should always be designed from the perspective of physicians. Doctors think differently than computer programmers – for the programmers, the EMR is their life’s work and passion – their entire work day revolves around the EMR. But for physicians, the EMR is just a tool that we use for the larger purpose of taking care of patients. If navigation within the EMR is done just because the program designer liked a similar configuration in the latest version of Fortnite, then it is a downgrade.

For the physicians:

  1. Don’t put your head in the sand and pretend that an EMR upgrade is not coming. The time to learn about the upgrade is not on the day that the upgrade rolls out.
  2. Lighten your load on the first day. If you double book your outpatient clinic or agree to cover one of the other hospitalists’ patients in addition to your own on the morning of the upgrade roll out, you are going to have a very, very bad day. You are better off leaving a few empty outpatient visit slots on your schedule or bringing in an extra physician or nurse practitioner to help with inpatient rounding that morning.
  3. Practice ahead of time. Most EMRs will have a practice version of new upgrades available that physicians can use with make-believe patients in order to get used to the new program before it rolls out. A few years ago, our family took a trip to rural France for a week – before the trip, I got on Google Maps street-view photos and practiced the route that I was going to be taking in the rental car from the train station to the town that we were staying in 30 miles away. I was glad I did because when we got there, I was half-brain dead from jet lag and the train trip so knowing which lane to be in at turns and what the street signs should look like kept me from getting lost in the French countryside.
  4. Take advantage of “superusers”. These are people who have already been trained in the new upgrade – often IT personnel – who wander around the hospital and the clinics for a week or two after an upgrade to assist doctors and nurses in figuring out how to use the new version of the EMR program. In our health system, they wear easily identifiable red jackets and we call them “redcoats”. They can save you time and prevent you from undergoing spontaneous combustion when you can’t figure out where all of the vital sign reports went to.
  5. Take heart, it will get better. In 1969, Dr. Elizabeth Kübler-Ross published her book On Death and Dying and in it described the 5 stage of grief when confronting a terminal illness: (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance. You are going to go through exactly the same stages when confronting an EMR upgrade. Eventually, you are going to accept it and you might even find that once you get used to it, that you wouldn’t want to go back to the old version. The only problem is that by then, there will be a new version of your EMR and another upgrade.

August 17, 2019

Electronic Medical Records Outpatient Practice

Should A Physician Pre-Chart For Outpatient Visits?

There is a subtle difference between inpatient and outpatient medical practice that nobody ever talks about… time management. With inpatient practice, you see patients at your own pace during rounds and if you want to stop for a moment to have a cup of coffee or speak with a colleague, it doesn’t disrupt your workday. But with outpatient practice, you can work leisurely at your own pace before office hours and after office hours but during office hours, you are in a constant state of demand for time efficiency.

In my own practice, my office hours come in 4-hour blocks, either 8:00 AM to 12:00 noon or 1:00 PM to 5:00 PM. During those blocks, I schedule 15 minutes for return visits and 45 minutes for new patient visits – every minute is scheduled and the only way that there is a break is if one of the patients doesn’t show up for their appointment. During that 4-hour block, I have nurses, schedulers, and registration staff who all need to be working in order for the office to function in a financially viable way. But for them to stay constantly busy, I have to be constantly busy.

10 years ago, before we adopted an electronic medical record, each patient would have a paper chart and I would make a few shorthand comments on a piece of progress note paper and then at the end of office hours, dictate letters to the referring physician for each patient, clean up my orders for the day and fill out billing sheets. In other words, I “back-loaded” my work day with a couple of hours of charting after I was done seeing patents. Once we adopted an EMR, I tried to do a lot of that work while I was in the room with the patient. The result was that I didn’t have as much dictation and chart work after office hours but the EMR documentation encroached on the time that I was with the patients. I continued to allocate the same amount of office time per patient but I seemed to have fewer minutes just talking with my patients. And because the EMR results in the physician doing more of the work of documentation than in the past, I still was spending an hour or two at the end of the day finishing referral letters and closing encounters in the EMR.

This was reflected on my CGCAHPS patient satisfaction survey results. Patients were happy with the care that they got but they were not happy about the time they spent in the waiting room when I ran behind and they often commented that they didn’t get enough time to spend with the doctor once they were in the exam room.

So 5 months ago, I tried a different approach, pre-charting for my outpatient visits. The day before my office hours, I start my progress note for each patient by selecting the appropriate return visit note template (I have different templates for different diseases: one for interstitial lung disease, one for asthma, one for COPD, etc.). I pre-populate any new test results and pre-populate my final “impression” by pasting in the diagnoses that I manage for that particular patient from their previous note. For new patients, I insert the appropriate new patient template (again, I have different templates for different pulmonary conditions) and pre-populate the note with any test results, radiograph image review, pulmonary function tests, etc. that are available for that patient, either from our medical center or from other hospitals that I can access through the “CareEverywhere” function in our EMR (we use Epic). As a result, I spend about an hour prior to each 4-hour outpatient block pre-charting, sometimes longer if I have a new patient with a lot of records that require reviewing. After 5 months, I’ve found that there are advantages and disadvantages:


  1. I am less likely to get behind on my schedule and so my patients are spending less time in the waiting room.
  2. I have more time to spend just talking with my patients since I am not trying to furiously type into the EMR as much when I am in the exam room with the patient. As a consequence, I find that I actually enjoy my time in the outpatient clinic a lot more than I used to.
  3. I anticipate improvement in two of the CGCAHPS survey questions: During this visit did this provider seem to know the important information about your medical history? and During this visit, did this provider have your medical records?
  4. I finish the day’s work earlier because I do less charting at the end of the day by front-loading all of that charting before office hours.
  5. I have now started billing CPT code 99358 about 2-4 times a week. This code pays you for review of medical records prior to seeing the patient in the office, as long as you spend at least 31 minutes doing the review. In my own outpatient practice, most of my patients have already had pretty extensive evaluations and in about half of the new patients, I spend > 30 minutes sifting through office notes, lab tests, cardiovascular tests, chest CT images, pulmonary function tests, etc. This pays 3.16 RVUs (about $114 in Medicare reimbursement) and I now find myself getting paid for the work that I was previously doing for free. And this adds up… I estimate that my clinical receipts will increase about $13,000 per year from this CPT, alone.
  6. I have x-rays available when I see the patient. Most of my patients are sent to me from physicians at other hospital systems and so most of their chest x-rays and CT scan images are not in our hospital’s computer system. By pre-charting, I have been able to identify where those radiographs were done so that my office staff can contact that hospital’s radiology department and have the images sent over the internet before I see the patient – in the past, I often had to schedule a second visit with the patient just to go over x-ray images that I requested after I first saw the patient for an initial consultation.
  7. I have been able to do a “huddle” with the nurses just before the start of office hours to let them know about anything special that they will need to do to prepare for each patient’s visit.


  1. In the past, I defined my workday as being complete when I finished all of the work for the patients that I saw on that particular day and the administrative duties I had for that day. Because pre-charting is often relegated to the last thing that I do each day (since it is usually the least urgent), pre-charting becomes the task that keeps me at work an hour longer each day and so I now negatively associate it with being the thing that steals my time away from my family in the evening.
  2. I often have residents and fellows in the office with me. I worry that by doing the pre-charting, I am detracting from their experience of independently analyzing the patient. Personally, I believe that the trainees learn a lot about how to comb through old records for diagnostic clues efficiently by actually doing it themselves and when I pre-chart, I am depriving them of this opportunity.
  3. I’ve created this nagging sense that I am becoming obsessive-compulsive.

Every time management strategy in the outpatient clinic has a trade-off between advantages and disadvantages. I don’t think that pre-charting save me any of the total time I spend on any given week but I don’t think it requires any more of my time either – it just shifts some of the documentation time around from after the clinic hours to before the clinic hours. But I think that it makes both my patients’ experience and my experience with the time spent in the exam room a little better. So, for now, I’m going to keep pre-charting.

November 28, 2018

Electronic Medical Records

30 Million Mouse Clicks And Then You Die

Someone once said that every person is born with a fixed number of heart beats and that our lives count down with each beat like grains of sand in an hourglass. I think the same thing happens with mouse clicks. If you do the math, it works out to about 3 billion heart beats during the average person’s life in the United States. In a previous post, I noted that the typical emergency department physician does about 4,000 mouse clicks per shift. That works out to about 25 million mouse click over the course of an ER doctor’s career. Add in another 5 million or so during medical school and residency and you get to 30 million.

So, if we can reduce our mouse clicks, can we live longer or have longer careers in medicine?

I figure that each mouse click takes about the same amount of time it takes me to speak a word. 30 million words would fit on 54,000 pages and fill 134 average length books. That is a lot of spoken words. Many physicians (and their patients) lament the amount of time that the physician spends staring into a computer monitor and clicking with a mouse during patient office visits. So, if our careers tick down one mouse click at a time, is there anything we can do to prolong them and reduce those mouse clicks that steal away the words we could be speaking with our patients? Electronic medical records are not going away, at least not any time soon. But there are some tangible things we can do to decrease our mouse clicks.

EMR designers need to engineer efficiency into the physician interface. When it comes to mouse clicks, less is more. The fewer mouse clicks it takes to navigate through a patient’s encounter, the better. This will often require the EMR to be able to be custom-configured by individual physicians so that the navigation through an encounter can take on the unique needs of that individual physician.

Staff must work at the top of their license. Whenever state and federal regulations permit, the medical assistant, LPN, and RN should be able to do as much in the EMR as they are allowed to do. Every mouse click that the MA can do is one less mouse click that the physician has to do and that equates to one more word that the physician can speak to or hear from the patient.

Physician should periodically re-train with their EMR. Most electronic medical records release periodic updates that improve on past versions. Optimization allows the physician to take advantage of these periodic updates in order to become more efficient with their EMR. But most physicians still use their EMR the way that they first learned how to use it when they went through their first EMR orientation. The strategic use of smartlists, smartphrases, and webpage customization can greatly diminish the number of mouse clicks it takes to complete a patient encounter.

Regulatory agencies need to eliminate unnecessary documentation burdens. In the interest of attempting to ensure high quality care, Medicare and insurance companies require physicians do document all kinds of things in the medical record. For every patient visit, we have to click to acknowledge that we have reviewed that patient’s problem list, allergies, medication list, and smoking history. The cold reality is that most physicians click through those items without really doing them – they are prompted to review these things before the encounter can be closed and the bill submitted – often after the patient has already left the office. The path of least resistance in this case is usually to go to the problem list page, scroll to the bottom of it, and then click on the button that says you have reviewed the problem list – most physician just click the button and never review or edit the actual problem list, which is often 30 or 40 entries long. And then there is all of the mouse click associated with billing – a click to link a specific diagnosis with each individual billing code, a click to add a -25 modifier whenever a procedure is done on the same day as an office visit, a click to add a -GC modifier if there was a resident or a fellow with you when you performed that office visit. These things add very little value to the actual care of the patient but steal away words that can be spoken with the patient.

Maybe reducing mouse click won’t really make us live longer or extend our practice careers. But reducing mouse clicks will free up a few extra minutes each day that we could be listening to our patients and talking to our patients.

November 4, 2018

Electronic Medical Records

Electronic Medical Record Whack-A-Mole

Mondays… I really don’t like Mondays. The only thing worse than a Monday is a Tuesday after a 3-day weekend. And the only thing worse than that is the day back to work after a week of vacation. Don’t get me wrong, its not that I don’t like being back at work being a doctor, its that I have to play Whack-A-Mole on the electronic medical record.

For the uninitiated, Whack-A-Mole is a carnival game where you use a giant mallet to smash down on wooden rodents that randomly briefly pop up from holes in a large table. The goal is to smack down as many of the moles as you can in a fixed amount of time. The problem is that the more moles you smack down, the more moles pop up.

So, what does a game that you play at the county fair have to do with electronic medical records? Well, the EMR has this feature called an “inbasket” where all of your patients’ test results, phone messages, email messages, verbal orders for signature, and medical record updates appear. As physicians, we “clear our inbaskets” by clicking on each item then acting on it; once completed, it disappears from the inbasket. It might be phone call from a patient you have to return, or an CT scan report that you have to review, or a medication refill that you need to send in to the pharmacy.

The goal of the EMR Whack-A-Mole game is to click on everything in the inbasket so that by the end of the day, the inbasket is completely empty.  On a typical Tuesday through Friday, EMR Whack-A-Mole goes at a pretty steady pace, you click on a message that a patient called about some new symptoms, call that patient, enter a telephone call note in the EMR, route an order for a medication to the patient’s pharmacy, then close the telephone encounter in the inbasket. A few minutes later, a new item will pop up in the inbasket and you have to open it, review it, and act on it. On a Tuesday, Wednesday, Thursday, or Friday, EMR Whack-A-Mole is pretty do-able so that the average physician can keep up pretty easily and have an empty inbasket at the end of the day.

But Mondays are something else all together. On Mondays, EMR Whack-A-Mole is played at a furious pace. There are 2 additional weekend days of pent-up volumes of patient phone calls, email messages from patients, medications that need to be refilled, and lab test reports. The result is that by mid-morning on Mondays, as soon as one inbasket item is opened, acted on, documented, and then closed, another item appears on the inbasket menu. A doctor can pretty much just sit in front of the computer clicking on inbasket messages and not do anything else for hours. By early afternoon, the speed of EMR Whack-A-Mole speeds up: for every 1 inbasket item that you open, read, act on, and close, 2 more items pop up. The best analogy is from the I Love Lucy TV show when Lucy and Ethel are trying to wrap candies coming down a conveyer belt.

After a 3-day weekend or a vacation, the pace of EMR Whack-A-Mole gets even faster. No sooner as you whack one thing out of your inbasket, 3 more pop up. The faster you whack your inbasket, the faster it fills up again. Pretty soon, the inbasket has grown into an enormous-sized monster. Patient phone calls come in faster than they can be returned and test results grow like rabbits fed Viagra.

By about 5 o’clock on Mondays, the inbasket slows down and you can whack out messages faster than the new ones appear. By about 7 o’clock, the last inbasket message gets whacked and you can go home. And then you can look forward to Tuesday for another game of Whack-A-Mole…

September 29, 2018

Electronic Medical Records Outpatient Practice

Why The Medication List In Your Electronic Medical Record is Wrong

The importance of an accurate medication list for every outpatient cannot be overstated. In theory, the electronic medical record should improve the accuracy of the medication list but in reality, medication lists are very often inaccurate. The act of verifying the medication list is called “medication reconciliation” which sounds so easy on the surface but is so hard in reality.

The Agency for Healthcare Research and Quality (an agency of the U.S. Department of Health and Human Services) says that there should be a single medication list that is the “one source of truth” for the patient and that medical practices should standardize and simplify the medication reconciliation process in order to make the right thing to do the easiest thing to do. But in most outpatient practices, mediation reconciliation is neither standardized, simple, or easy. Pull up any patient’s electronic medical record and if that patient sees more than 1 physician, there is a pretty good chance that the medication list is not accurate. Here are some of the reasons why:

  1. No stop date on short-term medications. Recently, I opened a patient’s chart and found that the medication list included amoxicillin. I asked the patient who said she wasn’t taking amoxicillin. So I pulled up the medication history and found that she had gotten a 7-day course of amoxicillin in 2009 (8 years ago) but it had never been taken off of her list. With electronic prescribing, a physician can set a duration of therapy (or set a stop date) and after that time, the medication falls off of the medication list. However, even if only 14 pills are prescribed with no refills, if the physician does not set the duration or stop date, then that medication stays on the list in perpetuity. I prescribe a lot of short courses of prednisone and antibiotics and so I have my own prescriptions for these commonly prescribed short-term medications in my “preference list” in our electronic medical record and these include a fixed number of days duration. But many physicians don’t have a preference setting for every antibiotic or other short-term medication that they prescribe and so if they don’t manually enter the stop date every time they write a prescription, that medication will continue to appear to be a long-term maintenance medication forever.
  2. Restricted hospital formularies. Hospital pharmacies cannot stock every single medication that is on the market. First, it is too expensive to maintain that wide of an inventory. Second, each hospital negotiates with various pharmaceutical companies or medication wholesalers for the least expensive of therapeutically equivalent medications in order to keep their costs down. As a consequence, when, for example,  a patient with asthma taking the inhaler Advair gets admitted to a hospital that does not have Advair on the formulary but does have the similar inhaler, Symbicort, then the admitting hospitalist will prescribe Symbicort while the patient is in the hospital. When that patient gets discharged, it is very easy for Symbicort to show up on the discharge medication list but since the patient does not know that Advair and Symbicort are equivalent drugs, that patient will start taking both inhalers. When that patient then sees a primary care physician, the medication list will include Symbicort instead of Advair even though the patient is now taking both drugs.
  3. “Don’t mess with my medication list”. Frequently, the responsibility for maintaining an accurate medication list falls to the primary care physician and in large, multi-group practices, specialists are often told not to take anything off of the patient’s medication list unless checking with the primary care physician first in order to insure that the list is, in fact, correct. The problem is that nobody has time to check with a patient’s primary care physician every time a patient says that they are not taking a medication that appears on their list so the path of least resistance is for specialist to never delete a medication from the list, only add new medications that they prescribe.
  4. Leaving medication reconciliation only up to the doctor. Medicare sets the rules for what nurses or medical students can document in the medical record and what the physician has to document. The “past medical history” is a chart component that nurses and medical students are permitted to document. The past medical history is supposed to include the patient’s medication list. Consequently, in many practices, the first time a patient is seen in that practice, the nurse will record the past medical history, including the patient’s allergies, previous surgeries, and current medications. Because it takes a lot of time to enter a long list of medications (including dose, frequency of administration, etc.), it makes sense to have a nurse or medical assistant do all of that documentation, thus freeing the physician’s time up to see more patients. But in many parts of the country, medication reconciliation is considered to be equivalent to prescribing a medication and so physicians are the only ones who can do medication reconciliation which includes taking medications off of the list when a patient reports that he/she is no longer taking them. Thus, the nurses can add to the list but only the physicians can delete from the list. This creates duplicate work and confusing responsibilities and as a consequence, errors occur. In the hospital, deleting a medication from the medication list directly affects the patient’s treatment and should only be done by a physician; however, in the outpatient setting, deleting a medication from the medication list is more justifiably done by a nurse if the patient says that they do not take that medication any longer. It is very important to distinguish the role and responsibility of the nurse in adding/deleting medications from the medication list in the inpatient setting versus the outpatient setting. Your practice has to decide whether maintaining an accurate medication list in the outpatient electronic medical record is part of recording the past medical history or a part of the medication prescription process – if you consider it part of the past medical history, then empower the nurses to do it.
  5. Medication lists cluttered with non-medication orders. In most electronic medical records, a lot of stuff that gets ordered ends up in the medication list because the EMR doesn’t know what else to do with it. Thus, disability parking placards, the influenza vaccine that the patient received 3 years ago, home oxygen, and wheelchairs will show up in the medication list. This ends up making the list excessively long and more confusing for anyone who is looking at it.
  6. What is the truth, really? Is the “one true source” a list of what the patient says that he or she is actually taking or what the doctor thinks that they are supposed to be taking? If you ask 100 doctors, 50 of them will say it is what the patient is actually taking and the other 50 will say it is what was actually prescribed. So, if a patient was prescribed a medication for gout, but never filled the prescription because it was too expensive, should that medication be on the patient’s list? One the one hand, it is the medication prescribed to treat the gout so you want to have that as part of your on-going medical record. But on the other hand, if the patient isn’t taking it, then should it keep appearing in the medical record? This is controversial and there is no perfect answer.
  7. Samples. If you give a patient a sample of a medication in the office, then you want to have documentation of them getting that medication, for example, a small tube of a steroid cream that a dermatologist gives a patient for their poison ivy. But once again, if there is not a stop date when you enter the sample in the medication list, then it stays on the list until someone else takes it off of the list at a later date.
  8. Bad data from other institutions. Many EMRs have the ability to interrogate other hospital systems that the patient has visited to pull in medications from that hospital system’s medical record. Even if the physicians in your hospital system are tediously compulsive about keeping an accurate medication list, unless the other hospital system’s doctors are equally compulsive, you can pull in errors into the patient’s medication list.
  9. There just isn’t enough time. When a patient gets admitted to the hospital, usually there is a nurse, a pharmacist, and a physician, all reviewing the patient’s medications. The patient is usually in the hospital for a few days so there is ample time for a thorough review and reconciliation with checks and double checks. But in the outpatient physician office, the responsibility for medication documentation often all falls solely the physician. Even if the office nursing staff participate, the time that the patient is in the office is so short that it is hard to get everything done. A typical physician’s return office visits are scheduled every 15 minutes. That means that in those 15 minutes, the physician has to review the patient’s history and any new test results, take an interval history from the patient, do a physical exam, discuss their findings and recommendations with the patients, order any new tests or medications, document a note, create a letter to the referring physician, enter their billing charges, and do the medication reconciliation. Often, there simply just isn’t enough time to do all of that and frequently the first corner to get cut is to skip the medication reconciliation. Some people would say that the answer is to schedule patients every 20 minutes, rather than every 15 minutes. However, over the course of a full day, that would equate to 25% fewer patients being seen that day and the reduction in revenue associated with 25% fewer patients would put most practices out of business.
  10. Poorly designed EMR workflows. A physician will naturally go to three windows in the electronic medical record: the progress note window, the test results window, and the orders window. Anything else and they will need a prompt. If the nurses in the office are permitted to mark medications for deletion but are not actually permitted to delete those medications from the medication list, then there has to be a prompt for the physician to go to that medication list window to approve those deletions. Otherwise, they will close that encounter without ever deleting those medications. Either the nurses should be empowered to delete medications that the patient says they are no longer taking or there needs to be a hard-stop to go to the medication list window before the physician can close the encounter.

The good news is that there are some concrete things you can do to reduce the inaccuracy of the medication list. Here are a few:

  1. Be sure that all short-term medications and samples have a  stop date in the initial prescription.

  2. Develop an agreed-upon consensus among all of the physicians in the organization about whether they define the medication list as the list of medications prescribed for the patient or what the patient says that they are actually taking.

  3. Develop an institutional policy that all physicians are allowed to delete medications from the list – the primary care physician or any specialist.

  4. Allow office staff to work at the top of their license with respect to adding or deleting medications from the outpatient’s list.

  5. Develop a simple practice to ensure that therapeutic substitutions made for inpatient formulary reasons at the time of admission to the hospital are substituted back to the patient’s normal outpatient equivalent drug.

  6. Create workflows in the office that are consistent so that everyone knows their role in maintenance of the medication list and performs that role on every patient.

  7. Design the electronic medical record so that the physician’s tasks for outpatient medication reconciliation becomes a natural part of the workflow or so that medication reconciliation is required before the encounter can be closed.

  8. Involve the patient by printing a copy of the medication list when the patient arrives to the clinic and having him/her review the list for additions/deletions.

November 6, 2017

Electronic Medical Records

Why You Don’t Really Hate Your Electronic Medical Record

The electronic medical record was created to make it easier to practice medicine. But the unintended consequence of the EMR was that it made it easier for regulatory agencies to tack on additional documentation requirements. It is the documentation excess that doctors hate. But like Pavlov’s dogs, we’ve come to associate that documentation excess with the electronic medical record. At its core, the EMR is just a place to store information about patients, just like the paper charts kept in manila folders that we used 20 years ago.

A study of the use of the EMR in emergency departments found that the average patient encounter required 194 mouse clicks. In a typical office practice, that number is probably about half that – let’s just say 100 mouse clicks. But as we move further toward value-based purchasing and risk-adjusted billing models of reimbursement, the number of mouse clicks per encounter will continue to increase. Lets take a look at where all of those mouse clicks go. We’ll start with a hypothetical patient who comes to the office for a return visit to check his blood pressure. What you really need to document is: “BP = 154/94 on hydrochlothiazide. Will add lisinopril 5 mg/day. Patient also has edema; will check creatinine and cardiac echo. Return to office in 2 weeks.” If you look back at hand written charts from 30 years ago, that is exactly what the progress note would say and it would have conveyed everything that the doctor needed to know about for that particular encounter and the doctor would have billed for a level 4 return visit (on the 1-5 scale of return visits). But today, to bill that level 4 return visit, the doctor has to add more documentation and all of that documentation requires mouse clicks. Here is the additional work that is now required in order to complete the encounter:

  1. Documentation of at least 4 signs or symptoms in the “history” portion of the encounter to meet Medicare requirements for billing a level 4 return office visit – 4 mouse clicks.
  2. Documentation of 5 signs or symptoms in the “review of systems” portion of the encounter to meet Medicare requirements for billing a level 4 return office visit – 5 mouse clicks.
  3. Documentation of 1 additional element in the “past medical history” portion of the encounter to meet Medicare requirements for billing a level 4 office visit – 1 mouse click.
  4. Documentation of 12 elements of the physical examination in the “exam” portion of the encounter to meet Medicare requirements for billing a level 4 office visit – 12 mouse clicks.
  5. Documentation of a minimum of 3 problems in the “impression” portion of the encounter to meet Medicare requirements for billing a level 4 return office visit – 3 mouse clicks.
  6. Documentation of whether the patient is a smoker in order to meet Medicare value-based-purchasing requirements – 1 mouse click.
  7. If the patient is a smoker, documentation of whether or not smoking cessation counseling was offered in order to meet Medicare value-based-purchasing requirements – 1 mouse click.
  8. Documentation of a review of all of the patients medications in order to meet Medicare “meaningful use” of the electronic medical record – 1 mouse click.
  9. Documentation of a review of the patient’s medication allergies in order to meet Medicare “meaningful use” of the electronic medical record – 1 mouse click.
  10. Documentation of a review of the patient’s problem list in order to meet Medicare “meaningful use” of the electronic medical record – 1 mouse click.
  11. Documentation of a Medicare-approved diagnosis code with the order for the cardiac echo in order for Medicare to pay for the echo test – 2 mouse clicks.
  12. Documentation of a Medicare-approved diagnosis code with the order for the creatinine lab test in order for Medicare to pay for the lab test – 2 mouse clicks.

If you add all of that up, it is a minimum of 34 mouse clicks (plus a lot of additional keyboard typing of various words) to complete the encounter and none of those 34 mouse clicks really adds to the care of the patient. Clever physicians have developed work-arounds in order to avoid having to do excessive documentation.

For example, they will create templates for their electronic medical record encounters that have all of the documentation elements for “history”, “past medical history”, “review of systems”, and “physical exam” pre-populated in their encounter note based on a typical normal patient, after all, the only person who would ever really look at all of that information is a Medicare coding auditor.

Other physicians will use strategies in the electronic medical record to automatically import information like the medication list, problem list, and allergies that had been previously entered into the electronic medical record during previous office visits – this results in long tables of data in the progress note with the result that the note is virtually unreadable to the clinician but has all of the necessary elements for the Medicare coding auditor to count.

Medicare requires all lab and imaging tests to be associated with a diagnosis and each test has a limited number of diagnoses that Medicare will accept in order to approve that test for payment. So, for example, Medicare will pay for a chemistry panel test for a diagnosis of “high risk medication use” but not for a diagnosis of “asthma”. On the surface, this sounds reasonable. But in practice, this can drive physicians crazy when they have to enter three or four diagnoses for an ordered test before they find one that Medicare (and therefore the electronic medical record) will accept for that particular test. Clever physicians have discovered diagnoses that can be used as “universal keys” to unlock the orders for commonly ordered tests – for example, the diagnosis “unspecified dyspnea” will work for just about any common lab test as well as an EKG, cardiac echo, chest x-ray, or pulmonary function test. Therefore, physicians often put “unspecified dyspnea” as a diagnosis, regardless of why the patient is being seen, just so Medicare will approve the test that they ordered.

The frustrating thing about documentation requirements is that regulatory agencies are always adding new requirements and they rarely if ever take away old documentation requirements. In other words, the number of mouse clicks per patient encounter grows each year, instead of shrinking each year.

A typical physician will schedule return patient visits in the office every 15 minutes. That means that they have 15 minutes to take an interval history from the patient, do a physical examination, review test results, counsel the patient, document the encounter, prescribe any medication refills, order any new tests, send a letter to the primary care physician, and complete the bill for that encounter. As the documentation mouse clicks add up, the physician has 2 choices: either extend the time for scheduled return visits to 20 minutes or reduce the amount of time spent talking with the patient. The net result of extending the encounter time to 20 minutes would be to reduce by 25% the total number of patients that can be seen in a day – this is not a viable option if the physician wants to stay in business. Therefore, each extra mouse click comes at the cost of a few seconds of time that would have otherwise been spent talking with the patient.

So, next time a doctor tells you that he or she hates their electronic medical record, what they really mean is that they hate all of the excess documentation that they have to do with the electronic medical record. It’s like of like hating pencils because you have to use them to fill out your IRS tax forms each year.

October 4, 2017

Electronic Medical Records

Flagellation With The Electronic Medical Record

Humans always have a way of making their lives harder than they really need to be. The electronic medical record gives us a great tool to do this and creates an opportunity for endless self-flagellation. Our hospital (Ohio State University) uses Epic, a pretty good electronic medical record. I also practice at Select Specialty Hospital that uses Epic. My wife practices in another hospital in town that also uses Epic but how the same electronic medical record program is used is completely different at each of the three hospitals. It illustrates how the same EMR can make your life easier in one place and be torturous in another place.

Past Medical History

At OSU, we load the past medical history, surgical history, smoking history, and family history into a location in the EMR where it can be pulled into every new progress note. That way, you don’t have to type all of the information into your note each time. At my wife’s hospital, the culture is that in the outpatient setting, this information should be obtained independently and typed in by every different physician who uses the EMR. So, the physicians spend far more time for each new H&P and each new consult that they create. Waste of time.

Medication Reconciliation

This is a problem for every physician and every hospital in the country. It means confirming what medications the patient is and is not currently taking. We do it whenever a patient is admitted to the hospital and discharged from the hospital. And we do it at every outpatient visit. It takes a lot of time and when physicians get busy, they usually don’t bother to update the master list of current medications in the chart. At my wife’s hospital, they are also required to do medication reconciliation for phone calls, even for simple refills. That means going through the entire medication list and confirming each medication, dose, and instructions. The problem: it discourages the use of the EMR for phone calls and refills since it is easier to just call them in to the pharmacy rather than send them in through the EMR and have to do all of the medication reconciliation.

Traditionally, the patient’s medications are considered part of the “past medical history”. For Medicare and insurance purposes, non-physician staff (RNs, LPNs, MAs, etc.) can enter information into the past medical history to update the patient’s record. This is enormously helpful for new patients when all of the patient’s previous medical illnesses, allergies, smoking history, surgeries, medications, and family history have to be entered into the EMR. An efficient medical practice allows all of the office staff to practice at the top of their license so that the physician does not need to spend valuable time typing in all of this information. At most hospitals, entering those historical medications is considered part of the past medical history so the MAs and LPNs can enter all of that information, leaving the doctor more time to spend with the patient. However, many hospitals consider deleting any medication that the patient reports that they are no longer taking as a medical order, meaning that it has to be done by a physician and not the RN, LPN, or MA. As a consequence, physicians have to manually delete any medications. Unfortunately, the “delete medication” window is not window that the physicians necessarily go to so most of the time, physicians fail to delete medications. Consequently, there is the potential to have medication lists that include 2 or 3 different doses of a hypertensive medication listed and have antibiotics stay on their medication list even though they only took them for seven days in 2009. Excessive regulation = bad data.


At OSU, we do our billing through the EMR so that when a note for a patient encounter is completed, you go to a separate window and enter all of the billing data. This is easy for outpatients because the program is set up so that you cannot close that particular encounter on the computer until you enter the billing data; so the encounter continues to appear on your EMR screen until you enter the data and close the encounter. For inpatients, there used to be no way of ensuring that the billing information was completed for daily notes; if you didn’t remember to open the “charge capture” window after you did a progress note, then no bill was created. The result is that 5-7% of all inpatient physician encounters can go unbilled. So, we worked with Epic to create a billing information window that would automatically pop up whenever a physician completed an inpatient progress note and this has significantly reduced unbilled encounters. In Select, there are billing screens in Epic but they cannot be tied into our physician billing department so the physicians have to complete paper billing sheets for each encounter. The problem: it can take an additional 20 minutes to fill out all of the billing sheets at the end of the day and many encounters go unbilled. Furthermore, many physicians do not realize that the billing screens don’t connect to our billing department and continue to enter the billing information in the Select Epic, wrongly thinking that the billing information is going to the billing department. Dollars lost.

Automatic Importation of Diagnosis Codes

When we open the charge window in Epic to enter our billing codes (CPT codes) for inpatient encounters, we also have to enter the specific diagnoses that we were managing with that encounter. At Ohio State, the Epic program remembers what diagnosis codes we entered the previous day and automatically imports them into the charge capture window, thus saving us from having to re-type all of the diagnoses each day. This is particularly helpful now that the United States is using the ICD-10 diagnosis codes that are very, very specific. So, for example, you can’t just enter a diagnosis of “ankle fracture” – you have to enter “ankle fracture, left, closed fracture, acute, subsequent encounter”. Consequently, it can take a long time to find the diagnosis that actually fits the patient. And since most of the time, the physician is seeing the patient for the same diagnoses every day of their hospital stay, automatically importing those diagnoses can save a lot of time that the physician could better spend actually taking care of the patient. On the other hand, at my wife’s hospital, the diagnosis codes are not automatically imported and so the ICD-10 codes have to be re-entered by the physician for each individual charge every day of the patient’s hospital stay. Total amount of time wasted: 5-10 minutes a day.


SmartLists are a selection of phrases that you can insert into a progress note that appear in a drop-down list allowing you to choose one or more of those phrases to insert into a progress note. For example, a SmartList for respiratory symptoms could include: “chest pain, shortness of breath, cough, hemoptysis” allowing you to pick one when you come to that drop-down menu. Epic comes with some built-in SmartLists but they are pretty generic and do not always fit the needs of the individual physician. So, at Ohio State, we have the capability of creating our own SmartLists with whatever words or phrases we want to include in them. However, Select does not grant physicians the ability to create their own SmartPhrases, thus forcing us to use phrases and words that may not exactly fit our needs. The result is that you either have progress notes that don’t really make much sense or the physician has to manually type in all of the words that he/she really wanted to use.

Required Allergy and Medication Review

At Ohio State, when a patient is admitted to the hospital, all of the medications and allergies have to be entered, but the order that they are entered doesn’t matter. At my wife’s hospital, the physician has to click a button attesting that he/she reviewed the allergies before the computer will finalize medication orders. But here is the thing… there is no prompt to review the allergies. So, if the physician fails to review the allergies, they can go ahead and enter all of the admission medication orders but after they are all entered, the orders cannot be signed until the physician goes back and clicks a button stating that they reviewed the allergies. The problem is that all of the medications that the physician just ordered can’t be saved so the physician has to go back and click the “review allergies” button and then re-enter all of the medications that were just deleted when they left the order entry screen.

You can measure how well your physicians are adopting to the electronic medical record by the number of 4-letter words uttered per hour while using the EMR. I call this the PPH (profanity per hour) index. If the index exceeds 20, then you have electronic medical record optimization opportunities.

June 22, 2017

Electronic Medical Records

How To Use Your EMR To Maximally Offend Your Referring Physician

Many physicians complain that they make too much money. One of the main sources of all of this unwanted money is from consults by referring physicians. In order to reduce one’s income, one very effective solution is to offend your referring physicians so that they send their patients to other doctors, thus causing them to make too much money. The good news is that electronic medical records make it easier than ever before to offend referring doctors. I’m going to show you how any specialist can use the EMR to achieve that ultimate goal of a lower income.

Confuse them.

In the old days, it was harder to be confusing. We used to dictate our referral letters and it was just way too easy to dictate phrases like “Helicobacter pylori”. This led to referring physicians understanding exactly what you were talking about. With the electronic medical record, it is now much easier to just type “HP”. The result of this is that the referring physician reading your letter now has to figure out, “Does he mean Helicobactor pylori? Or hypersensitivity pneumonitis? Or Hewlett-Packard? Or hypertropic prostate?” Abbreviations are a great way to confuse the readers of referral letters, especially those abbreviations that you make up. So, if the patient has pedal edema, put in your note “The patient had AS” – you’ll mean they had ankle swelling but the referring physician will think you meant aortic stenosis and order a cardiac catheterization! Try to put 1-2 abbreviations in each sentence for optimal effect.

Exhaust them.

When we dictated letters, this was really hard to do because dictating an interminably long letter took a lot of your time. With the EMR, we can now insert 10 pages of irrelevant results into a referral letter with a single mouse-click! There is nothing like making the reader of your letters wade through the last 30 potassium levels dating back to 2009 to tire them out. Many EMRs allow you to import all of the meaningless lab and test results into tabular format that is next to impossible to comprehend – a sure way to get the pesky referring physician to stop referring you more patients.

Disorient them.

A great trick I learned from one of our physicians is to vary where you put your impression & plan in your referral letters. Let’s face it, the referring physician could not care less about your review of systems, physical examination, etc. All they really want to know is what you think is going on and what either you are going to do about it or what you want them to do about it. So, the referring physician will automatically skip all of the irrelevant material and go straight to your impression and plan. By sometimes putting the impression & plan at the beginning of your note and sometimes putting it at the end of the note, you can keep them guessing about where to look. If you really want to disorient them, try sometimes putting your impression and plan in the middle of your referral letter! As an analogy, just think of how confused you’d be if the National Hockey League scores were sometimes in the sports section of the newspaper, sometimes in the arts & entertainment section, and sometimes in the middle of the classified ad section. The only danger is that if your referring physician likes playing “Where’s Waldo”, then he or she might actually enjoy the challenge of finding your impression & plan.

Baffle them.

Try writing your progress notes and referral letters in the same language that your teenager uses to text. Use letters like “u” instead of typing “you” and “r” instead of “are”. You can even abbreviate entire phrases like “IMO” for “in my opinion” and “HTH” for “hope this helps”. Whenever possible, drop verbs out of your sentences. Don’t capitalize anything. And remember, punctuation marks are for sissies.

Dodge them.

If you don’t like the question that the referring physician asked you, do what politicians do in a political debate – answer a different question! So, if you get consulted because of a patient’s chest pain and you are completely clueless about what is causing it, then find something else that you can work up, like their plantar fasciitis. There is nothing like “Dear Dr. Jones, Thank you for referring your patient to me for evaluation of crushing substernal chest pain. On exam, I find heel tenderness. My impression is that he has plantar fasciitis and so I will order an MRI of his ankle.” Although it is possible that the referring physician will think you are a genius for figuring out that plantar fasciitis causes referred pain that can mimic angina, it is more likely that they just won’t understand your letter. Another great way to get them to stop sending you patients.

Insult them.

When a referring physician sends you a patient, try to write your note in such a way to be as critical of their initial work-up as possible. If you get a consult for anemia, try inserting phrases such as: “Unfortunately, the patient’s physicians have not ordered screening colonoscopy as recommended by the American Cancer Society.” Or: “This is a textbook classic case of beta thallasemia minor that any 2nd year medical student should recognize.” If these are too subtle, try something more direct like: “The decision to order an iron level without doing a ferritin level was a really stupid idea.” I actually got a letter with a phrase like that in a consultant’s letter to me and so I never sent a consult to that physician again – if it worked for him, it can also work for you!

Belittle them.

A very effective way to alienate the referring physician is to depersonalize them by using phrases like “PCP” and “OSH”. So, if Dr. Smith, who practices at Mercy Mother of Suffering Sorrows Hospital refers a patient to you for consultation, don’t use Dr. Smith’s name in the letter, instead just put PCP for primary care physician. This will depersonalize the referring doctor and emphasis the fact that you consider him or her to be irrelevant and beneath you. There is nothing like starting your letter by saying “Dear Dr. Smith, Thank you for referring the patient to me. She has shortness of breath and her PCP found a new heart murmur.”. In addition to depersonalizing the referring physician, you can also depersonalize that physician’s hospital. Although Dr. Smith may consider Mercy Mother of Suffering Sorrows Hospital as the center of his medical practice universe, you can remind him that his hospital is just a generic small hospital and THE Ohio State University Medical Center is the true center of the medical universe. Using OSH for outside hospital is a very useful strategy. Try writing something like: “The patient had a cardiac echo at an OSH.” Just think of how irritated you would be if you asked for a consultation and the consultant sent you a letter referring to you as PCP and your hospital as the OSH.

By using some of these simple strategies, you too can reduce your income by cutting off the flow of consults from referring physicians. And your electronic medical record makes it easier than ever before to do it.

May 6, 2017