Clinicians: The Secret Weapon for Choosing and Evolving Electronics Health Records Systems

By Rachel Read, MS, OTR/L, BCG, CAPS

Electronic Health Records Clinical Director

Documentation is a necessary evil.

If you ask a clinician what is the most stressful part of their job, I bet the answer is documentation. Not only do they need to set aside time to complete this never-ending demand of the profession, but they need to make sure they effectively document the skilled care they just provided in order to ensure that the patient can continue to receive the care they so desperately need.

The rules and regulations of documentation are only becoming more stringent as reimbursement requirements increase.

The reality is that you can provide the most clinically excellent care to your patient, but it if is not documented, it never really happened.

TRANSITIONING FROM PAPER TO ELECTRONIC HEALTH RECORDS

In 2010, FOX Rehabilitation began the daunting task of transitioning from paper to an Electronic Health Records system. The first task was finding an EHR system that fit our unique model of practice. As a Medicare Part B practice providing house calls to older adults, what we do is anything but cookie-cutter.

We tried to implement a generic, out-of-the-box EHR system to our clinicians and it failed. We knew we had to do something better that fit our innovative model.

After some research, we found a system that would allow us to customize the EHR to our specific need: a perfect solution for a primarily clinician owned and operated practice.

We established a task force full of clinicians and set forth to customize the EHR system to meet the needs of our clinicians, patients, and payers. This team consisted of clinicians in various roles, even with one of our own physical therapists serving as the lead software engineer. Countless meetings were held and surveys were disseminated. Beta test after beta test was conducted to ensure every clinical touch was appropriate, justified, and met the practical needs of our clinicians in the field.

Clinicians of every discipline – occupational therapy, physical therapy, and speech-language pathology – were a part of the team that created all training materials and conducted the live training.

Having clinicians own the EHR system was, and still is, crucial.

WHAT’S DIFFERENT ABOUT OUR ELECTRONIC HEALTH RECORDS SYSTEM

Eight years have passed since we developed, validated, and launched our EHR system.

All along the way, a clinical team has been at the forefront of every change that has occurred within our EHR system. The clinical team with the Quality Assurance and Professional Development department receives the enhancement requests from the clinicians. The team sits together to decide, prioritize, and determine if the request is appropriate to incorporate into the EHR system.

Some deciding factors include if the clinical evidence supports the request, if it will streamline documentation, and/or if it meets the needs of the majority of the clinical practice versus the need of a small group. After a decision is made, the request will go to the software engineers to develop.  Once developed, the items are validated by the clinical team to make sure it functions as it was intended and no bugs exist in the new item. After the item passes validation, it is added to an EHR maintenance window to be updated into the live EHR system for use by the clinical practice.

This is what makes our EHR system unique. We, the clinicians, have skin in the game.

We want the EHR system to be time-efficient, easy, intuitive; and we want it to meet the needs of everyone that touches it.

Why? Because we also have to document in this EHR.

As clinicians, we know exactly how it feels to have the pressure of incomplete documentation looming over your head.

HOW AN EHR CAN EVOLVE

We continually make changes to the system to keep up with evidence-based research, standards of care, documentation requirements, and ever-changing regulatory demands.

We receive recommendations from our clinicians and do our very best to implement those changes. This can include, but is not limited to, requests for new functional outcome measures, screen changes to make navigation more time efficient, and templates for evidence-based practice protocols.

Taking every request into consideration is imperative. Our clinicians are documenting every single day and they know firsthand what is holding them up as they live and breathe in our EHR. Documentation is hard. It is time-consuming. It is the thankless part of the job.

An EHR system should be run by a clinical team. They know what is like to be in the weeds with documentation and have the best solutions to ease the stress of “paperwork.” If your practice does not have clinicians who are part of the EHR system, ask them how you can join the team. Be proactive and advocate to make your day to day life easier.