Dicey question, isn't it? I suppose if you took the question to mean will the job you do today be the same one you will do tomorrow.....the answer is ah no. The wonderful world of documentation creation is changing at lightening speed. We are at the start of a document sharing explosion via the digital highway. Are you ready?
EHRs are the talk of DC. I must say, it is amusing to see those whom we elect try to come up to speed on something that we have been aware of for a long time. The part that is not so funny is that these very same people are the ones who are making decisions that will affect if we continue to work at all. They do not understand that EHRs are a tool, not a panacea for healthcare as we know it. Without the clear understanding of meaningful use (and yes, that phrase is being bantered about by our elected officials), the data that is used to treat our patients will be compromised.
Oversight and editing by professional medical language specialists is crucial in the continuum of care and safety. I don't know how many of you have had the delightful opportunity to see what data is input in EHRs by physicians....I have, and it's not pretty or even remotely useful for that matter. For example, a physician documented this in the patient record after the patient had entered the ER and before the patient was moved to the floor:
" SoHx: No tob/etoh/drugs, lives home with son in law ROS: No fever, cough, CP, sob, abd pain, n/v/d, +constipation 3days, good urine output. A/P: 82 y female with AMS status post fall.
1. AMS - normal CT head, neurochecks
2. R/O Sepsis - nl urine, elev WBC, tachy, blood culture sent, Ceftriaxone
3. R Knee Injury - XR, uric acid level
4, CXR - possible retrocardiac infiltrate cover for pneumonia with Azithro"
Now, it's not all about making the document look pretty. It's about clarity of the patient record, which is the legal document that represents the patient and hospital, if litigated.
Even Dr. Blumenthal is confused, though excited, about the definition of meaningful use coming out of Washington. He stated recently about the definition of meaningful use, “Expect it to require providers to use HIT to reduce the amount of time spent on duplicative paperwork so they can spend more time with patients." Now, from a nonclinical point of view, that means that paperwork (really a term of the past) is looked at as the major problem. The reality is that the way documentation occurs (dictation-to-transcription) needs to be included in the terms when speaking of meaningful use. Capturing the patient's story is critical to excellence in patient care. We do not need to have our physicians or other clinicians inputting data. They clearly do not have the education or expertise to perform this task and further, we do not need to have higher paid professionals spending their valuable time on this as well. Their focus should be on direct patient care and our focus should be clinical support, documentation creation, and editing.
Here’s the rub people…. How do we maintain our place in the continuum of patient care? We become vocal at the local, state, regional, and national level. We mobilize when we hear of legislation that is detrimental to our profession. We activate our membership in AHDI, and we participate. No longer can we afford to stand by and watch as our association fights for our position without your help. No longer can we stand by and wait and complain that others do not UNDERSTAND and APPRECIATE what we do. No longer can we demand that others do the work that we will not do. We have to push credentialing and education. We have to be out there committing ourselves to our professions in real and tangible ways. If you are not willing to grow, educate yourself, and become credentialed, perhaps this is not (or no longer) the profession for you. Hard, yes. Real, yes. Timely, yes. It’s time to roll up our sleeves and get to work.
Read more: http://www.fiercehealthit.com/story/blumenthal-meaningful-use-must-result-quality-improvement-more-time-bedside-less-duplication/2?utm_medium=nl&utm_source=internal#ixzz0XiMoV9TS
