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PDF Editor FAQ

Has a patient ever died in a hospital due cumbersome paperwork process of the hospital?

I very much doubt you’ll get any anecdotal answers to this question so I looked up one case in the news. I think this case highlights the danger of routinely making up ‘admission packs’ for every patient. In an effort to save a little time it can lead to some very tragic outcomes.I found a very sad example of this happening in 2009, reported in the press in 2010:A man named Peter Clarke was admitted to hospital with a flu-like inllness and suffered a subsequent heart attack. The resuscitation team moved in but a nurse informed everyone that there was a ‘Do Not Attempt Resuscitation Order’(DNAR) in his notes.Everyone stopped trying to resuscitate Mr Clarke.Subsequently it was discovered that the DNAR form was blank and had been placed in his noted as part of the routine pile of paperwork that accompanies every admission to that hospital (included with other such forms as Waterlow score, MMT scores, Observation charts, drug charts, etc). It should not have been there. Mr Clarke was for resuscitation.Whilst it was unlikely that any resuscitation attempt would have been successful (owing to multiple comorobities) this is still a tragic example of how assumption and attempting to create an admission ‘template’ for every patient can go very wrong.I hope that the hospital learnt that you can’t simply treat every patient the same and everyone needs an individualise admission and careplan.This answer also raises the issue of realistic medicine, something that very recently has been the focuss of the Scottish Chief Medical Officer. This encourages open and honest discussion with patient regarding such things as the DNAR form. CPR is a very traumatic process and patients can have an unrealistic attitude as to the success of it. This discussion should have taken place with Mr Clarke and his family and whilst it is ultimately the medical team’s decision it should be made in agreement with the patient and his nominated next of kin.

What makes for a strong EMR (Electronic Medical Record) system?

Essential Features EMR Software Should Have:Smooth Interface and Systems Integration. You should consider the two common point of integration:HIS (Hospital Information System) if your practice is part of a larger institutional network.Billing records and system.The latter is essential for offering better patient services and improve the efficiency of your front desk staff. Billing integration also reduces the amount of payment delays, commonly caused by coding errors. Reimbursements are also processed at faster pace, electronically.2. Charting. Reduce the stress and hassle involved with creating and managing charts by spicing up your EMR software with the next features:Customizable chart templates to suit your practice needs.Voice recognition and dictation functionality.Optimize charts for portable devices e.g. tablets.Consider investing in machine learning, so that the software will learn the standard information, which generally goes into the record and streamline the whole process more effectively with auto-filling and prompts.3. Medication Tracking and E-prescriptionsYour EMR solution should easily track all the prescribed medication to your patients and have the information at disposal at any time. Additionally, you may consider adding extra functionality to determine how the prescribed medication interacts with other drugs being currently taken by the patient, issue incompliance alerts, notify about any potential allergic reactions or possible side effects. In the latter case, it should suggest some alternative treatment options.4. Integration with LabJust like with e-prescribing your staff will definitely appreciate the ability to electronically track delivery of samples; review and analyze the results and seamlessly integrate that data with charts.5. Appointment RemindersYour patients are busy and so are your doctors. Improve the communication standards by integrating an efficient reminder system into your EMR. It should be able to send quick notifications via email or text to remind of the appointments made.6. Evaluation and Management CodingYour custom EMR record can help you comply with the next requirements and significantly reduce the manual labor needed to keep those in order:Complete and legible medical recordsRelevant patient history and reasons for the encounter.Prior diagnostic test resultsPhysical exam findingsMedical plan of rateDate and identity of the observerHealth risk factors if any.Diagnosis and treatment codes.Patient progress and response to and changes in treatment.7. A Dedicated Patient PortalA patient serving themselves is the ultimate healthcare provider dream. That’s the task you can easily accomplish by integrating a dedicated patient portal to your EMR system.8. Cloud HostingCloud technologies are quickly pushing over the on-premise software, especially as the portable devices become more common at healthcare facilities. Your doctors will appreciate the ability to access healthcare records from any location and device if you opt for the cloud-based EMR software.You can find a more detailed guide here - http://bit.ly/emr-ehr

How does using an Electronic Medical Record (EMR) System affect the quality, content, and style of doctor's documentation/notes?

I would say that there is a difference between office EMR and hospital EMR that is important for patients to understand. The office EMR is basically one physician's work inputing data. The hospital EMR is like mashed potatoes. It's the work of a lot of doctors who are frequently harried and distracted, some who will only see a patient once. For a complicated 2 week stay in the hospital, that can be a huge number of doctors inputing into the EMR.For my office EMR, I'm basically writing the notes that I want to write but taking 3 times as long. Because templates have to be filled out, it's taking much longer to complete each note, order tests, and prescribe treatment. Completing the templates requires multiple endless tedious clicks. This is often done while speaking to patients, staff, or other doctors on the phone. There is a lot of room for error.At the end of the process, my note looks great. But instead of it being a neat couple of paragraphs, it ends up being 3-4 pages. This is just wonderful for coding and billing because it looks like I spent hours with a patient. But for nurses, doctors, and pharmacists, they have to scroll through a ton of crap to find out what I'm planning to do. This is even more of a problem with office EMR because almost all offices have different templates and there isn't any familiarity from one office to another. Doctors have to take a longer time deciphering other doctors EMRs to find the important impressions and plans.EMR adds a lot of time to the day and some doctors get around this by using a scribe. Isn't that brilliant you say? I went as a patient to a doctor recently and he had a scribe who inputed everything into the EMR. The doctor never touched the keyboard, but she typed intently as he spoke and at the end of the visit, he told her what to put down for diagnostic codes. He didn't glance at it once. A week later, I got a copy of the EMR note in the mail.Hey, that's pretty cool I thought at first. I looked through the couple of pages and then realized that it didn't say anything of substance. The EMR did list my medications and problems. But so what? There was no real impression or personal plan for my treatment that meant anything. It's as if the note were written before the visit just by listing the problems and having a computer write some general impression and plan. The note was just nonsense. I'm tempted to post it but I'm afraid if he finds out, I'll lose a friend and treating physician. After all, I'm seeing him for his expertise, not his EMR note.OK. I've so I've started my rant against EMR so let me continue. For those brave enough, read on.Contrary to pronouncements by those brilliant new Ivy League college graduate student systems engineers at RAND that proclaimed that EMR would make healthcare far more efficient, greatly reduce errors, and save tons of money, the data so far seems to show the opposite. And with time, it's getting worse, not better.It's definitely not more efficient and adds 60-90 minutes a day according to every doctor I've talked to. No one says that it saves time.EMR use can lead to errors in ordering and, in the hospital, can contain serious misinformation.How do you make an ordering error electronically?While Dr. X is ordering drugs sent electronically to the pharmacy, the patient and interrupting staff are cutting in with questions. Dr. X clicks on the wrong drug because it's right above or immediately below the intended drug. Off it goes to the pharmacy. Oh, but all you computer engineers say, Dr. X is supposed to read the drug dose and schedule summary before clicking send. He's supposed to review it before sending for crying out loud.But you engineers created this list for our convenience and all the drugs are listed alphabetical. So going down the list, the medications are all kind of similar looking sequentially down the row. At best, doctors glance at the prescription summary and because the wrong drug is just immediately above or below the intended one, it looks very similar at a hurried glance. Click while answering another question and off it goes. The wrong drug.This type of error doesn't happen in a handwritten prescription. And it wouldn't happen if you had to type out the medication name without help from the computer.I won't answer any questions or permit distractions when completing chemotherapy EMR orders. Zero. Period.EMR content errors happen much more often in the hospital than in the office. They are typically cut and paste errors. And what engineer would have thought that it wouldn't happen? You have multiple doctors working on multiple charts and continuous interruptions from other doctors and nurses. One busy morning, Dr. X finds herself logging out of patient #1 she is charting on to look up something on patient #2 to answer a question from a interrupting doctor discussing treatment options, and... oops! Dr. X forgot to log out and log back into patient #1. She's just completed her note on the wrong patient. That afternoon, Dr. Y takes Dr. X's note, cuts and pastes it to save time, and not too surprisingly, there are charts in the hospital that are wrong and dangerous.I have a friend who's full time oncology faculty at one of America's top 5 medical centers and he won't believe anything in the EMR without first verifying it himself. After the distracted interns, residents, and fellows finish cutting and pasting, some charts can be a mess. He goes into each visit and asks the patient, "Now tell me again, what cancer are we treating for you?" Wasn't the point of this EMR stuff something that's supposed to save time and reduce medical error?Oh wait, but what about reducing costs. EMR reduces costs, doesn't it? It couldn't possibly make sense for it not to. You know the story when the venders started selling these systems. EMR will reduce reduplicate testing and save loads of money for America. It does that doesn't it?Well...No. Studies indicate that EMR increases costs.Why? Because it's like going to a buffet for brunch.When you order a test on EMR, you get a menu and then you see that there are other things that look good to order. Thanks software engineers. Wouldn't it be better to just type in the test that you want so you don't get a menu?Dr. Z wants to get an ultrasound of the liver. He opens the menu and right next to the ultrasound he intended to order is CT scan, and next to that is PET scan, and next to that is MRI of the liver. Dr. Z says to himself, "I don't want to miss anything and the radiologists are so wishy washy most the time. They won't call anything definitively and invariably ask for additional imaging. I'm going to save time and order them all." 4 clicks and Dr. Z just ordered about $15,000-$20,000+ worth of tests in 20 seconds (only because he has to wait for each test to load).EMR has increased the ordering of expensive tests by 40-70%. Bet those braniac systems guys at RAND didn't anticipate that. Did anyone out there test these assumptions before making a national mandate requiring conversion to EMR in America? Apparently not.EMR has not made communication between doctors better, has not reduced medical errors in any measurable way, and also has clearly not lowered medical spending.***Everyone please get a copy of your hospital EMR and proof read it for errors before handing it in for your next doctor consultation.Electronic Records Systems Have Not Reduced Health Costs, Report SaysEHRs: “Sloppy and paste” endures despite patient safety riskDoctors to Lose Money on Electronic Records, Survey FindsWhy electronic health records failedWhy Electronic Medical Records Are Failing To Meet ExpectationsThe (So Far) Failed Promise of Electronic Medical RecordsDoctors order more X-rays, not fewer, with computer accessThanks for the A2A Ian Lee. I feel better now. Catharsis.

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