The widespread implementation of electronic medical records (EMRs) and electronic health records (EHRs) has significantly changed the quality and quantity of healthcare for both the better and the worse. The digitalization of medical records provides comprehensive documentation of all events and actions associated with an individual’s medical care. Likewise, legibility, accountability and credibility are greatly improved by access to all information pertinent to a patient’s healthcare.
Under the current fee-for-service reimbursement system (which is soon to be replaced by a fee-for-value reimbursement system), the EMR also acts like a giant cash register that tracks the quality and quantity of medical services provided that are documented to be medically necessary in order to reduce waste, fraud and abuse and maximize provider accountability and reimbursement for medical services.
So what’s not to love? Plenty!
The Bad & the Ugly
The sheer volume of documentation that is displayed all at one time may overwhelm the healthcare provider, who can get distracted in locating the information he needs in a sea of medical documentation that the provider must somehow confirm has been reviewed. Ultimately, the healthcare provider is taking care of the EHR demands as much as the patient, if not more.
Thoughtful consideration of a patient’s concerns and complaints, along with formulation of a diagnosis and treatment plan (not to mention examination), is undermined by the inflexible demands of the EHR program, which will not progress to the next task until all tasks required are completed. What used to be a one- or two-page succinct document describing an office visit has morphed into a 6–10-page regurgitation of previous medical records that may or may not be relevant to current healthcare needs (also known as note bloat).
Pressure to Diagnose
In order to facilitate care, the healthcare provider is required to provide a diagnosis to proceed with permission for further diagnostic and therapeutic efforts, regardless of certainty that the diagnostic label is accurate and correct. The key to the kingdom of both therapy and payment is the diagnostic label, which, hopefully, is accurate and reflects the correct diagnosis.
A medical diagnosis involves the identification of the nature and cause of illness symptoms and the determination of the cause of an associated disease process. Sometimes, symptoms of illness are not associated with a defined disease process, and sometimes, a disease process is silent and not associated with illness symptoms.
Illness is how a patient feels (subjectively reported), and disease is the identification of abnormal body tissue and/or function that can be measured directly by examination or indirectly by diagnostic studies.