Resources & Information

This issue’s President’s Message is a cautionary tale for those of you using electronic health records. Now before you scoff and call me a technophobe, let me explain.

I’ve been using EHR in my own practice since 2003 and, overall, it has been a positive experience. I firmly believe that a good system, well used, forces a physician or physician assistant to think in an organized manner. The process of completing the EHR entry can help ensure that the patient record thoroughly and accurately documents what went on during a patient encounter.

As a member of the Board I’ve seen enough examples of illegible, chickenscratch, handwritten records to understand how valuable that is. From the Board’s perspective, it’s relatively easy, upon review of a well done EHR, to reconstruct what happened during a given episode of care and make some determination about the appropriateness of a licensee’s actions. Clinicians who use their EHR systems effectively may be confident that, if needed, they will be able to defend their records and their care.

Here’s the problem: Everyone who is using an EHR system isn’t necessarily using it well. The Board has noticed an increased instance of disciplinary cases in which improper use of EHR is a factor. The problems fall in two main categories:

1. The licensee is overusing template content provided through the EHR, which results in incomplete and/or inaccurate records.


2. The licensee lacks the time to become proficient in the use of his or her EHR, which results in incomplete and/or inaccurate patient records.

EHR template content: NOT a substitute for a good exam
Sometimes the errors or omissions in poorly executed EHRs are glaring and ridiculous. For example, in the course of reviewing a case, the Board may look at a record that purports to accurately document a physical examination of a female patient. Yet, upon review, it is determined that the record indicates that male genitalia were examined, with no abnormalities present (a great relief to the patient, no doubt).

Here’s a brief sampling of other EHR-related documentation errors observed by the Board and its staff:

• A morbidly obese woman with a history of four C-sections and two laparoscopic ab-dominal procedures described in the record as having a “flat abdomen” with “no scars.”


• The records of a patient with chronic cellulitis, chronic epididymitis and chronic low back pain contain exams that do not match the history, with numerous “normal” skin, musculoskeletal and neuro exams.


• A patient is prescribed increasing doses of opioids for low back pain, although records show the history of present illness is identical for many visits, raising questions about the need to continue/increase opioid therapy.

Why are these sorts of errors problematic? First, it diminishes the value of the record to other treating clinicians, who will glean little meaningful information about the patient. And from the Board’s perspective, a template-driven record raises doubts about the overall quality of the licensee’s care. To be blunt, how careful can the Board assume an examination was if the licensee describes a female patient as having male anatomy? What else might the licensee have gotten wrong? Did the licensee even examine the patient? Obviously, this is not the direction a licensee would want the discussion to move in when his or her case is before the Board.

To be sure, template content in EHRs can be helpful. It can improve billing by ensuring that insurance company requirements are met. It can save time by reducing the need for the practitioner to manually enter each component of care. However, templates cannot take the place of a good, detailed, accurate physical exam and history. All of us are under incredible time pressures and it may be tempting to rely on templates to get through your documentation more quickly. Don’t do it. Bottom line, if you didn’t do something, don’t put it in the record. When you do use templates to document an exam, take the time to customize the record to ensure you document it accurately.

Don’t know how to use your EHR? Get help
That brings me to my second assertion, that many problems the Board sees with EHRs has to do with the fact that licensees are too swamped to make the time to learn to properly use their EHR system. I suspect this is the case for most of the licensees we see with evident problems using EHR well.

Learning to properly use your EHR is absolutely critical. Truly, how can anyone afford not to? I know taking days or weeks out of already packed work schedules to learn a new system is difficult. But when one considers the extremely high cost to purchase and run most EHRs (typically at least a few thousand dollars a month, plus a sizeable upfront investment), investing the additional time and expense to train on the system is negligible.

Many established EHR vendors have intensive training available, for an additional fee. However, to address the specific concerns raised in this article NC AHEC, which received a federal grant to help medical practices become meaningful users of EHR, may be an even better choice. A primary goal of the NC AHEC program is to help practices use EHR to help improve care and satisfaction for practitioners, their patients and staff.

NC AHEC had a tremendous response to its grant program, which provided free or subsidized training to primary care practices. It is now in the process of transitioning to a fee-based EHR training service that will be available to clinicians in all practice areas. Learn more about the service or sign your practice up as a potential client, email the program administrators for more information.

Until next time,
Ralph