When I started in ophthalmology more than a decade ago, charting was done solely on paper. We struggled to read doctors’ handwriting, and patient appointments were written in a physical appointment book.
As the youngest employee in the office, I was assigned to help with paper migration, and I witnessed firsthand the growing pains of electronic medical record (EMR) systems. I’ve seen EMR systems come and go, some of which caused as many inefficiencies as the outdated systems they were meant to replace. However, I have found that certain tips and tricks over the years can be used to ensure we use the EMR system to its fullest capacity. This advice can be applied to many (if not all) available EMR systems. (Even though, in my opinion, not all EMR systems are created equal, we will not be discussing the pros and cons of certain systems.)
Let’s start by taking a birds-eye view of the clinic and examining how various ophthalmic staff members use an EMR system.
Work-up technicians
Most EMR systems have a Chief Complaint/History of Present Illness function. In most cases, if you are simply using the “out of the box” function to create a CC/HPI, it is not only inefficient but often does not give the provider the necessary information. With that being said, there is usually a way to arrange the functions so that your techs can produce CC/HPI efficiently. You can often present some common phrases (be mindful of what phrases you are including) and arrange the phrases in a way to generate a HPI that reads coherently. With the 2021 E/M coding changes, the CC/HPI drives the exam even more than before. If you have not reviewed your system's CC/HPI function in some time, I would encourage you to do so.
I’ve worked up and scribed through many “updates,” and once staff can get through the initial shock of these updates, you may find some helpful changes. I’ve learned to read through the pop-ups regarding the changes and trial the additional buttons or triggers. For example, some systems redo their formatting to make it easier to see the work-up components once installed. If you find that work-up technicians often complain about “all this clicking,” you may want to call your EMR provider to see if there are new options to limit the number of clicks during a workup.
A word of caution here: It is important to understand the limitations of your EMR system and properly train your staff on protocol. For example, if the work-up technician needs to update the primary care physician, they should know how to do this quickly and efficiently. Where can your work-up technician make that change in your EMR system? Do they send the updated information to someone to change or add it to your system? Does this need to be communicated to the provider, and what is the best way to do that? How about the steps for updating the patient’s pharmacy? This may seem trivial, but I have watched technicians spend precious minutes trying to update PCP and pharmacy information because they did not know which buttons to click in the system.
Diagnostic technicians
If it isn’t complicated enough getting accurate scans, photographs, etc., we often must learn how to get the results from the machine into the EMR system. Occasionally, it takes longer to get the image into the EMR system than it does to take a quality image. If you find this is the case, reach out to your EMR representative and ask if they have new programs that can help make the transition smoother. You may find that new technology or upgrades are available, and it can make quite a dent in your patient wait times.
Scribes
Last but certainly not least is the EMR efficiencies that can be hiding in your exam documentation functions. Again, if we can get over the initial shock of EMR updates, you may find some helpful changes. These changes can include quick buttons that may add an exam finding to the assessment and plan section.
Efficiency can be built into the exam by using canned notes in the plan section of your exam. These notes should be reviewed yearly for any needed tweaks in phrasing or terminology. As insurance companies constantly update their requirements for documentation, ensure that your canned notes reflect these changes. Once the canned notes are created, I encourage scribes and providers to use these notes but to make edits specific to each patient. These notes should be considered an outline for the visit, but you should create additional treatment notes based on what was discussed during the visit.
If your EMR system has a billing/coding section, please review this yearly for updates and/or changes. I find occasionally that helpful coding guides and prompts are added during EMR updates. Some EMR systems can assist your provider in selecting the proper codes based on the data input from the work up technicians and scribes.
In closing
No matter how efficient or inefficient the EMR system is, it does not make up for poor staff training. We are aware of the time crunch we face in the exam lanes, and searching for EMR buttons can only make matters worse. It is essential to teach technicians and scribes how to properly and efficiently use the EMR system. Have them sit with a senior staff member who is considered a “super user” for their EMR training.
Also, learn to “welcome the update,” as I like to say. It’s going to happen anyway, right? Prepare your staff as best as you can by researching exactly what the update is providing. Do a test run on the new features before showing your staff how to use it, and provide feedback to your EMR system administrator. EMR systems have come a long way since I first started 15 years ago, and our continued feedback drives the improvements we’ve seen in recent years. I encourage you to take some time and look at your EMR system and how it impacts your clinic flow. You may find that some simple steps can create big changes. OP
