The Dangers of EMR

Does the use of an electronic medical record system have a negative impact on our patient care?

By Dena Aitken, PT

Over the last 10 years, electronic medical records (EMR) have become commonplace in all aspects of health care and physical therapy. With today’s increased regulations and coding requirements, good software that guides and assists is essential.

However, I would like to caution all providers on allowing our EMR systems to replace our professional skills and knowledge. I see this repeatedly in health care, when doctors go through a list of questions, and based on the answers to the prompts the computer produces, they generate a diagnosis. As a patient, you might leave thinking, “Did the doctor really listen to what was actually going on with me or did I just conveniently fit into one of their computer based categories?”

One of the advantages of our skill set is the ability to analyze a person from a musculoskeletal perspective and determine the epidemiology of the patient’s pain or dysfunction. With today’s common use of EMR in therapy, are we in danger of just filling out the form? I often hear from therapists that they want drop-down choices to expedite the documentation process so they can easily just pick and choose. My concern is that the drop-down menus bias or limit a therapist to those specific options. In addition, something could be missed because it was not a choice in the EMR software. In addition, the therapist/patient interview can become just a question and answer session to fill in the blanks of that particular system, rather than conducting an interview that evaluates all of the factors of a patient’s problem.

We have the incredible opportunity to spend time with our patients, which is a distinct difference from many other health care providers. We typically see patients multiple times a week over several weeks, which allows us to develop a relationship with our patients. This relationship ultimately leads to positive outcomes and loyal customers. By utilizing an EMR, I think it is easy to rely on the system to diagnose our patients, to set treatment and goals for our patients, and to forget about using our interviewing and listening skills to determine treatment.

Solely relying on EMR can lead to insufficient documentation and payment issues. When documenting, the human thought process must be behind the content instead of a pre-determined cascade of information generated by EMR. Documents need to stand up legally by detailing the ins and outs of the patient encounter.

This is best accomplished by the following:

• Implement a customer service program at your facility and meet with your team on a regular basis to discuss the essentials of a good therapist/patient interaction and how you envision the role of EMR within this program.
• Avoid the concept of therapists’ heads buried in laptops trying to stay up to the minute on documentation—documentation is a fact of life, but it is important not to let it take away from the personal touch of therapy.
• Continue to question any automated response/diagnosis that an EMR system may produce based on your input. In the end, it is your name and signature on the documentation; ensure it makes sense for your situation and correct the record from your professional viewpoint.

Each therapist should find the passion, the mystery, and the real patient with each encounter as opposed to just entering the facts into EMR. By doing so, we will improve patient loyalty and ultimately have better outcomes.

Dena Aitken, PT, is a PPS member and co-owner of Greater Therapy Centers in North Texas. She can be reached at daitken@gtc-pt.com. Adam Aitken is principal of A2C Medical. He can be reached at aaitken@a2cmedical.com.