Charting is too difficult. Each individual chart is not too bad, until you multiply it by 25, 30, or even 60 patients a day. How much of our charting is actually beneficial, and how much is just for compliance? How much is just to appease the insururs. Insurance companies are interested in making a profit, so if they can increase the administrative burden on doctors, then they see less patients, and insurance can pay less. If doctors are burned out, then they will be more inclined to scoot patients out the door without extensive treatment plans. How much do these insurance companies influence the amount of charting doctors have to do? Lets put it another way- how much can tens of millions of dollars in lobbying money affect the charting process for doctors(1)? A medical profression is a regulated profression, so when the major donors to lobbying efforts are the insurance companies, who is really calling the shots here? Then we come back to EMRs. EMRs are a complex and bloated peice of software. They must record every piece of vital information for every visit for every patient that ever was or will be in each practice. Not only that but every sentence ever typed, deleted, or adjusted must be recorded. It's recording your every move! To satisfy the demands of every insurance and legislation means that the user interface becomes an after-thought. Even though the interface is what will make a difference to the doctor trying to do their job, who can then pass that value onto the patient.
I've spent a considerable amount of time trying to fix my charting experience. It's been an uphill battle because the EMR I have been stuck with is possibly the worst for eye care- E-Clinical Works (ecw). Every little element has it's own segregated page. So if you want to deal with the refraction- separate page. Final spectacle Rx- separate page. Not even assessment and plan and billing is on the same page. The amount of windows and sub-windows that must be navigated creates a crushing mental burden on the doctors using it. To keep the patients clinical findings and HPI's in your mind, while conceiving of a treatment plan- simultaneously calculating where to put what information into the chart, making sure it is worded correctly- all the while with the patient asking you the same quesiton for the 3rd time or rambling about unrelated stories- creates an unbearable mental crucible. While the solution to this is going to be more nuanced and complicated, here are some thoughts I have on the matter:
Many are looking to AI to fix everything wrong with their charting experience, but we see EMR companies slapping AI tools into their chart just for marketing purposes without really fixing the underlying user-experience. If a home didn't have the electrical wired properly- then adding wi-fi won't fix it. While AI has the potential to make significant improvements, if it is applied with the same level of thought and care that the originial interface was, then the user-experience is going to be even more broken. Everyone is already tired of the low-quality AI receptionists who talk you in circles and clearly don't understand you or what you are trying to accomplish. You've likely had the experience of spending all too much time trying to get an AI to do what you need. Imagine that in your EMR. A refined macro system can easily rival or even beat an AI. Macros are wildly under-utilized and under-developed. I have developed, and am continuing to refine Mr. Macrows- a superior clinical macro program built by a clinician, for clinicians. Some of it's features include menu macros. These macros take you through a series of menus where you can make selections applicable to the patients situation and at the end it spits out a highly specific note. For example, with diabetic eye exams there are so many possibilities in the outcome. Do they have diabetic retinopathy or no? What stage is the retinopathy? Which eye? Is there macular edema with it? Every combination of these makes it impractical to create macros to cover every possible scenario. With a menu macro you don't have to. Another feature is reference material. Doctors can't, and shouldn't memorize every little piece of information, but looking things up takes too long. Mr. Macrows allows you to pull up a comprehensive list of contact lenses with the dkt, lens material, diameter, available parameters, and even fit set availability- all with a few keystrokes, and without having to leave the EMR window! I have saved countless minutes quickly determining whether or not we should have a lens trial in office, and whether or not a particular lens comes in a patients prescriptiong- all without leaving my chair, or even my EMR window. This will be expanded to include information on medications and drops (what pharmacy do I send this drop to again? What bottle size should be dispensed?), as well as clinical norms (what was the exophthalmometry reading supposed to be?). These are things that the developers of EMRs are not thinking about, nor are they prioritizing. It's not that our old technology is insufficient, we just need to maximize it.
My current EMR purgatory involves navigating a multiplicity of windows and sub-windows. Every little element of the chart requires navigating to a new window. It took some fanagaling but I was able to bring the eye exam, billing and coding, and the assessment and plan into one page- and I felt an immediate relief. I was then able to bounce around between these different parts of the exam in real time and dump everything in my mind onto the EMR. The EMR was not built for this, and it required me to create templates for every conceivable icd-10, CPT, and EM code-which was then accessible from the template search bar on the side- and then create an extra persistent pop-up box to enter my assessment and plan into. That's a lot of manipulation to get a function that should have been baked into the EMR to begin with. Any video editing software such as Premiere Pro or DaVinci recognizes that there are multiple features that you are going to need throughout the video editing project. You will need to adjust the color temperature, the sound, special effects, transitions, and so on. They provide a platform with multiple boxes in one screen. You can add effects, clip the timeline, adjust the text, view your media bank- all in the same window! Some EMRs do this better than others, and granted mine does it the worst, but this is a vital and overlooked feature. We should have customization as to what appears on the main screen. Maybe we want to access the refraction, eye exam, billing and coding, and assessment and plan all on one page. Perhaps a particular doctor prefers to separate the examination elements and the billing and coding. This level of "build-it-yourself" interface should come standard. The other thing video editing software excels at is keyboard shortcuts. Once you learn or create a catalog of key shortcuts you can cut, delete, shrink, expand, play, stop, and much, much more with single letter keystrokes. If we are to manage a patients treatment plan, record clinical findings, prescribe medication, provide their glasses prescriptiong, manage contact lens trials and from those select a final contact lens prescription, enter the appropriate icd-10 codes, and bill accurately with the return to clinic interval as the cherry on top- then by golly, it ought to be easier to navigate through. Keyboard shortcuts can not only help navigate through the many elements of a patients chart, but also send actions such as printing, faxing, converting, vertexing etc. Many of these features exist but they are buried under multiple keystrokes, clicks, and excessive navigation. We need to clean out the house, and streamline the processses that already exist.