PracticalDermatology

Electronic Health Records (EHRs) have made strides in solidifying their place within modern healthcare. Physicians looking to implement an EHR now have a range of choices, with many vendors in the market. The system one chooses will depend on a number of considerations. This article will explore several factors to consider in EHR implementation and use, both for new system purchases as well as refinements to established EHR systems.

BASIC REQUIREMENTS

Server vs. Cloud

An area of debate in EHR selection revolves around the question of whether to choose a “server-based” or a “cloud-based” platform. Selecting between these two options may depend on an individual physician's preferences. Both offer advantages and disadvantages. Many appreciate the potentially easier start-up of cloud-based systems. If time pressure is not an issue, though, a server-based system may offer some more appealing advantages. For instance, server-based systems offer greater day-to-day connectivity-reliability, greater average throughput (including broader initial bandwidth and better comparative performance) for program performance, and full control over data. Though the upfront costs initially may be more, the long-term costs compare favorably with the long-term costs of a cloud-based system, since monthly costs tend to be greater with the latter.

Laptop vs. Tablet

Another consideration for EHR users is the electronic device that will be used for operating the EHR. With the novelty and popularity of user-friendly tablet devices, many physicians choose tablets over laptop computers. However, laptops offer a number of advantages over tablets for the more complex tasks involved in medical work and practice affairs. In terms of usability, laptops offer more screen real estate, a feature that facilitates navigation through the many screens of an EHR and makes orienting and training new recruits easier. Also, because most people cannot type as quickly or accurately on a virtual keyboard, the standard keyboard of a laptop, with its function keys, shortcut commands tab/escape keys, and perhaps even a numeric keypad, allows faster patient processing and data entry.

Customizable vs. Programmable Templates

When it comes to making an EHR work effectively in practice, templates are essential for faster documenting. Two main template approaches are available, which might be termed “customizable” and “programmable.” With customizable templates, the user may change some-to-many discrete variables, but template and flow structures generally are unalterable. Programmable templates, on the other hand, offer a more substantial ability to alter what is seen and included within a template. Programmable does not have to mean arcane computer coding—rather think more of macro creation in a word processing document. Programmable templates may be created that more closely simulate the approach that a practitioner used while documenting on paper. Because programmable templates may be better individualized, documentation speed may be increased and satisfaction enhanced. Programmable templates may require a more significant upfront time commitment, but likely will pay significant efficiency dividends over the course of time.

EFFICIENCY ENHANCEMENTS

After establishing platform, equipment, and templateapproach choices, physicians can further optimize their use of an EHR in several ways:

Utilize Scribes

Scribes offer advantages over the physician-workhorse documentation model. A scribe allows the physician to focus attention on the patient during the visit. After the encounter is completed, the physician can move immediately to the next patient, while the scribe continues to produce a final H&P draft for physician review. This approach allows for a more streamlined clinic workflow for the physician. It also enables a more efficient final-draft review and signature session once patient care is completed. Finally, it decreases data-input tedium and weariness for the physician.

Scribes will require a certain amount of training to achieve proficiency, and a bright, adept typist is a must. The cost-benefit ratio for scribes also may be a concern, though most practitioners find that the time saved documenting allows additional patients to be seen, which more than covers overhead costs.

Delegate Duties that Others Can Legitimately Perform

To enhance efficiency, a physician generally should perform only those tasks that s/he alone can complete. Responsibility for all other tasks should be assigned to trusted staff members.

Tasks to delegate may include:

• Answering patient phone-queries
• Documenting patient communications
• Completing refill requests
• Filling out appeal and verification forms (e.g. prior authorizations, cancer claims, etc.)

An effective delegating system requires a well-trained and capable staff. Further, clear lines of responsibility must be established to ensure proper execution of tasks.

EHR Images: Link Them, Rather than Embed Them

EHR images are best employed as supplementary data, to be called upon only when required. Many images are not essential in reviewing a note, and proofreading is more effective without them. Linking images (a link within the document) to the H&P, rather than embedding them (an image within the document), reduces the length of the final H&P, while also reducing H&P upload-time and shortening the paper copies that may need to go to referring providers or others. This approach may concede the “wow” factor, but offers up the speed factor.

EHR Images: Link Them, Rather than Embed Them EHR images are best employed as supplementary data, to be called upon only when required. Many images are not essential in reviewing a note, and proofreading is more effective without them. Linking images (a link within the document) to the H&P, rather than embedding them (an image within the document), reduces the length of the final H&P, while also reducing H&P upload-time and shortening the paper copies that may need to go to referring providers or others. This approach may concede the “wow” factor, but offers up the speed factor.

Keep Those Paper Charts: Paperless is Not a Panacea “Paperless” is appealing conceptually but experientially is a more complicated reality. “Paper” in some measure still offers advantages in a medical practice. Paper charts keep one's options open in an unpredictable world. Importantly, they reduce the potential problem of electronic documenting- blackouts. Paper charts also allow patient data to remain within the practice's control, not at the discretion of a thirdparty thirdparty vendor. Moreover, paper may provide a busy front office staff with the structure that facilitates accountability in an age of quality-reporting and meaningful use requirements. Finally, paper keeps patient data readily available for outside-the-patient's-room review, a process that is faster “on paper” than the navigation required in an electronic system. Such advantages arguably outweigh the downside: the standard costs involved with paper.

Reviewing Previous Notes: Print H&Ps to Speed Your Work Flow

As affirmed above, sifting through printed notes is faster than electronically navigating among prior H&Ps, path reports, lab reports, communications, etc. Consider: the following navigation steps are required to effectively review electronically a patient's record prior to a visit:

• Opening the patient's electronic file
• Maneuvering to the proper electronic window
• Scrolling down to the section of interest, perhaps in a long document
• Navigating through various data files

Moreover, by employing the scribe-documentation model, the physician may handily review the paper patient documents, while the scribe begins and progresses through the current visit's note.

Study and Optimize Clinic Flow, From Check-in to the Finish

Because EHR use (including the federal Meaningful Use program) fundamentally changes the way patient encounters proceed, physician practices must modify front and back office protocols to maintain efficiency. Therefore, it is important to take an active role in studying the various steps required in the patient encounter process. Physicians often are the bestequipped to make global decisions about the patient flow process. Meetings with staff to problem-solve system difficulties and bottlenecks will also pay efficiency dividends.

CONCLUSION

At the end of the day, physicians should pursue an EHR model that is physician-friendly. One should investigate promising EHR systems that naturally fit individual practice style, then strive to tailor the selected EHR system to fit that practice style as comprehensively as possible. Further, physicians should evaluate the patient flow process to optimize clinical efficiency. Finally, physicians should delegate all tasks that office staff members can legitimately perform.

Erin S. Gardner, MD is in independent practice in St. Louis, Missouri, and uses McKesson's Practice Partner EHR.