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Subject:  Re: OT: Career crisis Date:  10/15/2005  3:12 PM
Author:  xraymd Number:  212571 of 312956

Greetings, Chris, I'd hoped you would answer. The coding aspects for codes that recur are not the ones that cause difficulty. Here's what does:

On paper, the chief complaint and a portion of the HPI are written by the medical assistant at the time she takes and documents the vitals. Then I see the patient, ask a few more focused questions, write the answers swiftly, examine the patient, write my exam findings just as swiftly, write any rx's and prepare any forms for imaging and labwork and record point by point what my diagnoses are and what I am doing to treat and investigate. The minute I think it, I can write it. I have not been obliged to hunt up the ICD-9 code for my diagnoses. It's quick and I am done once it is on paper. Next patient up next, nothing left over from the first patient.

On the EMR, I must open the patient visit, go to the specific module intended to capture chief complaint/history of medical illness, put the individual complaints into their individual boxes (the medical assistant does some of this), put the vitals into a different module into their individual boxes, go to the review of systems module and click off each little box regarding Normal or have to open yet another module to detail any abnormal review of systems, go to the physical exam module and click on each little box similarly to the review of systems module - and every time I answer that something is not Normal, yet ANOTHER box pops up asking me to further detail the degree of abnormality which I have to answer or close, then I have to go to the Assessment module to search the ICD-9 database for every single diagnosis I wish to document (when I know the codes it's easier but when I can't find them it's a showstopper because the program WILL NOT PROCEED without ICD-9 codes for everything). Having spent time to find the codes, I then have to go to the Plan module to say what I am doing for each diagnosis, then I have to go to the Rx module to put in every single prescription (each time having to re-enter my password because it is not set up to allow me to input it once per session or even per patient) that I wish to print out - sometimes I can't even find the desired med when I search for it - then I have to go to the printer to collect all my scripts to sign. Then I have to go to the lab module to enter lab requests that I used to simply circle. Then I have to go to the imaging module to detail requests I have for imaging - xrays, CTs, mammograms, bone density scans. Then I have to encode the results of any EKGs I've done (can't just write it anymore on the EKG itself - have to ALSO do this). And this is just for urgent care visits. For Establish Care visits, I have not even mentioned what needs to be done to capture past medical history, social history or family history on this system - each with their own modules with multipart steps for each, and none of the modules passes information forward to the payoff Assessment module which, if not completed, causes a block to closing off the patient visit.

And all of this needs to be done in 15 minutes, otherwise the patients are stacked up waiting. I used to run on time (contrary to the schedules that several of the other docs keep) and I can STILL run on time if I do not spend time doing any of this during the actual visit. The problem is that the mechanical aspects of recording on paper were very fast - I could write nearly as fast as I could think, and I could do so simultaneously with my attention focused on the patient. But I am simply slower on the computer - the mechanical aspects of clunkily moving from module to module have really slowed me down since I evidently can't think and click at the same time, and the patients rightfully dislike being slowed up by my attention to the monitor and not to them.

How have the other docs done it? One of the docs is a superstar. He's able to be both fast and thorough simultaneously and is considered in a league by himself. I watched him for an afternoon - he never falters. It's like watching a piano concerto by a gifted master - he already knows what he is going to have to type and he is able to type and talk to a patient at the same time with blinding speed. The other docs admit to cheating on their coding - they enter fewer diagnoses and they cut out any detail that might be relevant for future lookbacks on how a patient was doing at the current visit. In other words, they've decided to compromise on detail rather than get bogged down - if they have a definite diagnosis that is too obscure to find in ICD-9, they IGNORE it. The most senior doc in the practice has already realized that having to code on this system is going to mean a major overhaul of how he has done things successfully for nearly 30 years and he has delayed his start date yet again because of realizing that he can't afford to adapt or die given the hit it will mean for revenue. I've sort of hoped that when he tries it, should he realize that he's better off doing what he's always done and handing off his paper documentation to someone else to enter, that maybe the same courtesy would be extended to me. Not everybody is likely to be as successful at assimilating this method of data capture, and apparently I am not. If I were to compromise and enter only a couple of diagnoses per visit - even if there were yet more that were pertinent - perhaps I would be faster, too, but what does that say about how I will recall the plans 3 months down the road?

The bottom line is that I have been struggling with this for too many months and am by now just exhausted. It has been made very hard not being able to be fluent in documenting simultaneous with the visit itself. I have been spending effectively an additional half-day after seeing patients on pure documentation and there just are not that many hours in the day. So I am doing less than ever before and taking longer to do it, and nobody is happy.

Are you on EMR and have you adapted? Thanks so much for your comments. I agree it shouldn't have to be this hard!

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