Wednesday, April 25, 2007

Video of EMR in my practice


Jean-Fran├žois Rancourt md said...

fine! In my paperless office I choose to put my note after visit of my patient. A part in structure note and a part in a dictate note transcript by my staff.
I'm not ready to put data in the exam room, lot a change in our habit. As you say it's probably the future...

Michelle Greiver said...

Merci, Dr Rancourt. I do essentially the same thing. I think that if you enter the entire encounter with the patient there, you spend too much time with the computer and not enough with the patient. I enter a small amount of data (example, headache x 2 days), as well as data that are likely to be less accurate if entered later, such as blood pressure numbers. The majority of the encounter is entered after I see the patient.

The small bit of data during the encounter also acts as a "place holder", so that the encounter is kept open and I don't forget to complete it (and bill for it).

Some things are much faster if entered later, such as templates. I also have "history builders", which are strings of words, for recurrent history and physical findings (normal neurological exam, advice regarding Gardasil etc).

I think that this may be what happens with many physicians using EMR: bits of data entered during the encounter, some structured data entered during or shortly after the encounter, longer unstructured or free text data/templated information that may be done any time later during the day to complete the encounter. This longer data is where many people will choose to dictate/type/use templates/use word strings.


Gabriel said...

I think that entry of patient information can be done at the time of the encounter. I think it really depends on the speed of the typist (if using a keyboard system). I am usually able to complete my entire note while the patient is in the room with me. I try to condense the information as they are narrating it to me and I include it in the chart. I find that templates are more of a reminder to me, or a way to keep data looking uniform, than a time saver. I think that as more and more of the younger generation that have grown up with fingers welded to the keyboard take to EMR, the more complete the notes will be when entered in the exam room.

Michelle Greiver said...

Thanks, Gabriel. My resident types faster than me, and I type pretty fast. You are probably right, amount of data typed in at the point of care will increase, and dictation may be less attractive in some fieds of medicine. I think that for highly narrative areas, such as psychotherapy, dictation may remain a popular alternative.

When my office is very busy, I find that splitting data entry between point of care and later works best for me. If I'm very tired at the end of the day, I go home and have supper, and enter the rest remotely afterwards. I don't truck bags of charts home anymore.