An EMR should never do the thinking for you

With several years of experience providing EMR software to Physical Therapists all over the country, we have heard a million different needs for a million different scenarios. One of the more surprising requests is the desire for a system that "does all the work for me."

We have thought a lot about this request and decided that it is rooted in education. EMR is the future of healthcare and with the future comes ideas of artificial intelligence and flying vehicles. We aren’t there yet, and I’m not sure EMR will ever get to that point.

Why can't an EMR just do it all for me?

One of the main reasons is that EMR is not a solution, but rather a tool. Its a tool to help you do what you already do, only faster, better and for less money.

You spent all of those years slaving over the books and gaining all that expertise; it would be a mistake to assume that software could replicate all of the nuanced human elements that go into a patient visit. With that in mind I would like to say, ‘No, the system will not complete your note for you.' Some other EMR providers come close to this. They allow you to simply check off some boxes without the ability to elaborate. The notes that come out of those systems read something like this.

_________________________________________

Shoulder

Operative

Operative Procedure

TSR

History

            Fell off bike and hurt shoulder

Objective

AROM

            WNL

Plan

            3/week

_________________________________________

Patient Care

This note doesn’t pick up on any of the nuances of the patient, it doesn’t accurately cover the conversation that occurred during the subjective portion of the exam, and it doesn’t allow anyone in your office, or any other medical office for that matter, to take your information and use it to better treat and care for this patient. There must be an element of professional responsibility in an EMR. It must be designed to allow you to do what you do best; treat patients.

Legal Ramifications

As EMR becomes a more relevant topic, some have raised questions about the legal ramifications that may result if you simply check off the boxes. What if there is a negative outcome and you have to ensure your documentation provides ample evidence of your treatment? When you present the above note as evidence, I am sure there will be a barrage of tough questions coming your way. If your EMR wasn’t so rigid and allowed you to use your medical knowledge in your examination, you would have a detailed account of the patient, their injuries, and your testing and care.

Human Touch

There is a fine line between what an EMR can do and what it should do. The human expertise is needed more than ever in healthcare and allowing an EMR to guide clinicians down a predetermined path isn’t the best way to document. With WebPT, for instance, we allow you to template out cases that you see often, but you always have ample room to test anything you like and type out notes and nuances that your patients will give to you in a visit. You can completely switch courses in the note and pick up right where you left off.

When searching for an EMR, make sure you have ample opportunity to make educated decisions about your patients without being guided by a rigid EMR.