Editor’s note: We hear a lot about the stress and lack of time for direct patient care that nurses (and physicians) have experienced with the movement to EMRs or EHRs. We’re in a transitional period, and in some instances the use and design of these systems has a long ways to go. But here’s a story with a positive slant, written by someone who might easily have responded very differently, given the circumstances. Change is inevitable; how we react to it throughout our lives, less so.
By Marilyn Kiesling Howard, ARNP
I am a nurse practitioner and my husband of 60 years is a family practitioner. We still work full time in our Gulf Breeze, Florida, practice. About five years ago, we first learned that our paper records were becoming archaic and that Medicare was planning to penalize providers who didn’t switch to the use of electronic health records (EHRs) by a certain date.
It was terrible news—we had 50 years of work in the paper chart genre, and were unsure about how to make the transition. Some who were in our position took the pending requirements as an opportunity to retire, but we weren’t ready for that.
Embracing a predigital innovation. In the 1960s, we started a small family practice in Indiana. As we requested our patients’ records from the files of their most recent physicians, it was not unusual to receive an index card that had the date neatly stamped on the left edge, with a handwritten note on the same line. (Needless to say, we’d already gone upscale, with a folder for each patient and a piece of white note paper.)
We quickly found that the medical record was our link to the prospective health of our patients, so we explored how we might make our records more useful. Joe read about a clinic in Bangor, Maine, where physicians were implementing the problem-oriented medical record (POMR) developed by Dr. Larry Weed, so we flew there to learn about this innovation. Dr. Bjorn and Dr. Cross were still developing their application of the model; their favorite medical secretary was a ‘bored bright housewife,’ and the entire clinic had an aura of excitement and discovery.
When we returned home, we quickly converted our folders to a proper chart with the ‘problem list’ fastened on the left and the progress notes on the right, using the new methodology. As we treated our new patients, we dutifully produced the ‘subjective, objective, assessment, and plan’ (SOAP) model we’d also imported from Maine.
This method sufficed for all the years between the first enlightenment and our leap in May 2011 into the world of pixels. It’s a challenge to get up and running with an EHR system. It was as if we were starting a new office with 2,000 patients to enroll. We had to had to translate and enter all of their old information into the new charting system. Two of our staff did not have computer knowledge and could not type. We went to half production, and our lost revenue was felt for months afterwards. (‘Meaningful use’ rules reimbursed us for about one-half of what the transition cost us.)
We’d decided on a cloud-based system because it was easy to access and the records would be safely stored on a server in Maine, an extra plus due to our propensity for hurricanes in the Florida Panhandle. The program was extremely user friendly. Given our level of expertise, this was a necessity. We took lessons online; the training included a live operator who was willing to stay on the line until the information was understood and applied. The company that runs the system keeps us compliant with meaningful use requirements and lets us know of impending changes.
We have, since we started using it at our clinic, found the EHR so far superior to our handwritten method that it would be impossible for us to return to the scribbled messes, as we see our old charts now. We still refer to them to garner important items such as consults, colonoscopies, surgeries, etc. Those reports are then neatly bar-coded into the EHR. It is no longer necessary to weed, retire, or store the charts. We did not abstract the old charts, simply moved important reports from them. We keep them in our office for quick historical reference.
The benefits are endless: sending records to other doctors and hospitals is so simple. The patient portal allows patients to send messages to our ‘buckets’ and find their lab and X-ray reports easily. In many instances, the offices are closed when records are necessary for complete care in an emergency. Our patients can access their records on the portal any time.
They can pay a bill online, change their addresses, and we are able to make templates to help patients with self-care, such as taking their blood pressure at home.
Don’t forget hands-on care. While this is leading to better quality of care for the patients in the future, it’s also true that, as we made the transition, we noticed that ‘hands on’ care was affected. An anchor of our practice is that an important part of the healing process is the human touch. This is waning as healers are touching the keyboard more than the patient. While we’ve said farewell to the paper chart’s unwieldiness, illegibility, problematic storage and retrieval, and the challenges of sharing its contents, we are keeping a watchful eye on the disappearing use of human contact and communication, as well as on preserving patient privacy.
Enjoy the transition, and get on board.