Do your physicians actually complete the charting in real time during the visit?
Dr. Buehrens: As for completing records, some of us, myself for one, complete every chart at the time of the visit. Indeed, it is a delight to be able to hand the record to a patient to take to a referral specialist or to the hospital!
Others are not so facile, and take their ThinkPads home to complete charts. We audit that process, and everyone knows where they stand. Some choose to feel ashamed, but we believe in transparency and in adopting best practices. Some courageous physicians have taken a half-day to shadow the best performers to learn their tricks, and we have had our trainer physicians role-play patient visits and complete the notes in real time during member meetings.
Are your reports readable in the sense of how your previously dictated records sounded, or are they more robotic in quality?
Dr. Buehrens: Our notes usually have MA-created basic histories from text or drop down menus, which read as narrative. Physicians then add to that. PEs are templated normals with charting by exception. The assessment and plan is a narrative, typed entirely by the physician. We find our notes to be quite adequate, more complete than dictation, faster and certainly cheaper! Prescriptions are almost entirely electronic, chosen from dropdown menus, often with templated instructions. All of the templates can be edited, deleted or added to. Special forms for various types of encounters allow just in time customization. We chose Centricity because little customization is required, but it is still possible. Some EHRs require a great deal of customization before beginning.
I am interested in an EHR system. I have a large solo Gastroenterology practice and I am using ProVation for our in-house endoscopy unit. Which EHR system are you using and have you heard much about ProVation for office-based EHR and billing?
Dr. Buehrens: I have no information about ProVation. We chose GE Centricity about four years ago and have never looked back. We’re very happy with the product.
Submit your questions for Dr. Buehrens to hit@ama-assn.org.
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