I love your video! I am a new lawyer and have to review medical records constantly. I find it very tedious and frustrating because, like you said, most of the records are just copied and pasted so I start to gloss over things and may miss important client information. It also doesn't help that because I'm new I am still learning what to look for. The copying and pasting is so outrageous that I reviewed a 25 page (super short compared to other 2500 page records I've done) where the useful information was only about 4 pages long and then the rest of the pages were literally copied and pasted versions of those 4 pages over and over again! It also makes it difficult to see where one document ends and the other begins and on which date that document began and ended because they all run together without a break in between documents! I think another thing that can help the problem is having a table of contents at the beginning of the medical records that state the name of each medical record that appears and what page it starts and ends on. I reviewed one medical record that had this and was very helpful because otherwise you're just thrown in without much of a reference point as to what document you're reading or what date the document was taken. Thanks for the video and glad to see someone in the field thinks they're a mess😀
Great information ! Imagine the IT side who is trying to convert the EMR data into useful supplemental data for quality initiatives. I wonder how much % of these notes make into the already big data system.
@@ahealthcarez I have seen some very poor outcomes from very smart professional care involving people I cared about. This is more than an academic issue to me. Please continue to highlight this and related topics. For example cross shift or cross health care network communication.Thank you.
Archived records. Archived Hippa, lack of personal contact between medical professionals, personnel transience, I could go on. As I say, it is a very pregnant topic for me.
that's where Clinical Documentation Improvement (CDI) is helpful, few companies have developed AI system that helps physicians to write stuff that matters in reimbursement which also cuts down on back/forth call between coder and physicians to figure out what to code!
Great review! What are your thoughts about medical apps that you can speak into on your phone and it can "share information "with your EHR as not to have staff input and do"double work"? Do you think apps will replace EMR 's?
I used to work in Life Insurance and part of risk assessment requires all the medical records, especially high face value policies. Feel bad for those that have review an 80 year old’s Shakespeare volumes.
I just started a new job in pain management where most of my patients are established and have been there for years, the progress notes are carried over from previous notes that are carried over from previous notes and so on. I don’t know how to determine what was done last visit or 10 visits ago, or where even to put my note for the day after I carry the old note over. Everyone seems to get it but me. To me it just seems like everything is jumbled together and there’s no rhyme or reason to it. I doubt that is the case, it’s just how I feel. I hope it becomes clear to me soon bc it’s keeping me in the weeds. 😮
I live in a place on the other side of the spectrum most of our complex cases have poor documentation thus our hunger for EMR Wouldn't referrals help avoid half of hamlet
Good information.. I would have never known this information had i not decided to pursue medical billing and coding. The ehr and all that that entails is interesting, i never knew that physicians had documentation requirements. Apparently they didn’t either lol
Doctor, Can you tell me if I want to sue the Hospital on grounds that the electronic records purported to have been transcribed by an outside company were not transcribed by the outside company till a month later, do I file a case in the State or the Federal Court. It is a HIPAA matter? The records eliminated all ER records and put in a paragraph of a drug that was given. The particular drug was given at a later stage causing overdose and damage to the Brain (as told to me by the Neuro of the ER ). The records were given to our attorney and were believed by the law firm to be accurate. Pro se in New Jersey.
I am confused. This detail you speak of that is required to support billing - do you mean both with insurance companies and Medicare? I never see this information in a treatment note. Is it someplace else??
Unfortunately, current state EMR's are being built primarily for data collection, not for provider ease of use or improved quality of care. This disparity is giving rise to career opportunities to those in the CDI field where the golden nuggets, as you say, can be gleaned @ the pre-visit stage and prompted to the providers for capture @ the point of care.
SCRs are for data sharing and things like COVID Programmes You have a primary record and SCRs can be used for anything regardless what they tell you - OPT OUT
As you know, this is just scratching the surface or our inefficient and gaping deficient EMR/EHR platforms. Here are a few of my observations as an QI RN Clinical Compliance Auditor that spent 10 years in the field auditing and training Medical Practices for Health Plans and the State of CA as a Certified Master Trainer. #1 Accurate Information loaded into the EHR is critical and when Practices receive Health Plan eligibility list "E-List" these are chronically wrong. Keep in mind the Practices are responsible to engage these patients for preventive screening and disease management in some type of shared risk agreement with the HP/IPA and Practice contract. Therefore that Practice is ultimately responsible for each encounter and to complete these encounters in a timely and comprehensive manner. #2 The paperwork that is given to that patient as they sit in the waiting room pre-visit is often several pages of Information including a listing of multiple medical problems,SDOH questions , past medical treatments,ADL questions and multiple other forms needed to have signed for the billing and treatment consent. Let's be honest, we know the Patient has limited understanding on what they’re reading and "checking the boxes" and signing. Furthermore why couldn’t much of this Information come from there previous insurance and previous PCP? The company we are working with has streamlined and increased the efficiency of this specific process in the comfort of that patient home but I'm not here to promote myself. Just pointing out this is a huge barrier to capturing a comprehensive visit and render proper treatments and the billing effectiveness. #3 Our laws have mandated that EHR's be able to be migrated to other EHR's and be part of a Health Information Exchange "HIE" Furthermore Practices are required to have "Patients Portals" to allow patients to have access to their EHR's. The compliance of the above is minimal. #4 The "Follow Up" Most visits require some f/u. Whether it's a medication a referral to a specialist or multiple other reasons. The bottom line is less than 50% of these f/u visits are completed and very minimal efforts are done to follow through and close the loop. We know the fact that 85% of MediCare eligible aged (65+) have at least 1 chronic disease. In contrast less that 10% of these patients that are MEMBERS of MediCare Advantage Health Plans are in any type of Chronic Care Management Program. In some Plans less than 5%. Less face it our system is complicated and fragmented and somehow the Health Industry operates in the 80s-90's, uses FAX machines and is in denial of the SaaS platforms and RPM programs that would increase interoperability. Yes I'm bias towards "management of care" in-between' office visits with Telehealth and RPM but I honestly don’t see any other Solutions Sorry so long of a reply
I always have a problem with these software and administrators at large. Some of them are so clueless about what goes on with the people who are actually using these tools. Sometimes, the disconnect is irritating. 😮
Doctors notes are exactly the problem. I pray every time I change doctors that the new one will ONLY look at labs and imagining. I actually ask the doctor to please not read notes but only review labs. But they won't do that because they don't want to look at the same labs and document a different diagnosis. Not because they aren't sure but because they don't want to document errors of each other... You make excuses for each other all the time and people die because of it. And I am over the excuses I hear all the time: Doctors are over worked. Doctors are taught to prescribe... Doctors aren't taught... So a "doctor" stands before me with at least 8yrs of study of the human body and you don't have a clue how to fuel it or what to do if you can't write a prescription... Patients need to be more informed and hold their doctor accountable... You don't get to tell me "I must" and when it goes bad tell me "I didn't know"...
I stopped what I was doing to comment and subscribe. I see patients notes larger than textbooks. I can bet that something important will be missed. Even control F to find things is not helpful. It’s such a mess.
Are there smart text features where commonly used phrases can be selected in EHR? Just curious if custom features exist too. My team is currently building an app and we were asked to add copy to clipboard feature so they can paste in EHR? 😅
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I love your video! I am a new lawyer and have to review medical records constantly. I find it very tedious and frustrating because, like you said, most of the records are just copied and pasted so I start to gloss over things and may miss important client information. It also doesn't help that because I'm new I am still learning what to look for. The copying and pasting is so outrageous that I reviewed a 25 page (super short compared to other 2500 page records I've done) where the useful information was only about 4 pages long and then the rest of the pages were literally copied and pasted versions of those 4 pages over and over again! It also makes it difficult to see where one document ends and the other begins and on which date that document began and ended because they all run together without a break in between documents!
I think another thing that can help the problem is having a table of contents at the beginning of the medical records that state the name of each medical record that appears and what page it starts and ends on. I reviewed one medical record that had this and was very helpful because otherwise you're just thrown in without much of a reference point as to what document you're reading or what date the document was taken.
Thanks for the video and glad to see someone in the field thinks they're a mess😀
Thank you for watching and sharing your experience.
This topic deserves more attention. I speak from several personal experiences.
Thank you for watching and for your support.
Makes sense why my records said I was coughing for a year and a half after having the flu 😭
Thank you for watching and for your comment.
Thank you for sharing your experience. I am not a doctor, but I can feel your pain.
Thank you for watching.
Thank you Dr Bricker for taking time to share your experience. I'm learning a lot from you:)
Thank you for watching!!
Great information ! Imagine the IT side who is trying to convert the EMR data into useful supplemental data for quality initiatives. I wonder how much % of these notes make into the already big data system.
Great point. Thank you for watching.
Yes as a nurse this is 100 percent true for our notes and epic charting as well. I love that, “chart lore”.
Thank you for watching and sharing your experience.
@@ahealthcarez I have seen some very poor outcomes from very smart professional care involving people I cared about. This is more than an academic issue to me. Please continue to highlight this and related topics. For example cross shift or cross health care network communication.Thank you.
Archived records. Archived Hippa, lack of personal contact between medical professionals, personnel transience, I could go on. As I say, it is a very pregnant topic for me.
@@ahealthcarez We debate who pays for health care in the US, We do not debate how it is delivered, which is very problematic.
that's where Clinical Documentation Improvement (CDI) is helpful, few companies have developed AI system that helps physicians to write stuff that matters in reimbursement which also cuts down on back/forth call between coder and physicians to figure out what to code!
Thank you for sharing your thoughts. Appreciate you watching.
Unfortunately when I attempt an assessment, asking questions, patients 85% of the time say, "its all there in my record." 😕
🤦♂️ Maybe say, “Humor me.” 🤷♂️😉
Thank you for watching and for your comment.
Or, "would you like your medical records to be accurate or not?"
Why not use medical scribes to handle EMR?
Good suggestion. Thank you.
Thank you.@@ahealthcarez
Great review! What are your thoughts about medical apps that you can speak into on your phone and it can "share information "with your EHR as not to have staff input and do"double work"? Do you think apps will replace EMR 's?
Good question. I don’t know. Thank you for bringing this to my attention.
I used to work in Life Insurance and part of risk assessment requires all the medical records, especially high face value policies. Feel bad for those that have review an 80 year old’s Shakespeare volumes.
#True. Thank you for your comment.
I just started a new job in pain management where most of my patients are established and have been there for years, the progress notes are carried over from previous notes that are carried over from previous notes and so on. I don’t know how to determine what was done last visit or 10 visits ago, or where even to put my note for the day after I carry the old note over. Everyone seems to get it but me. To me it just seems like everything is jumbled together and there’s no rhyme or reason to it. I doubt that is the case, it’s just how I feel. I hope it becomes clear to me soon bc it’s keeping me in the weeds. 😮
Thank you for sharing your experience.
I live in a place on the other side of the spectrum most of our complex cases have poor documentation thus our hunger for EMR
Wouldn't referrals help avoid half of hamlet
Thank you for watching and sharing your perspective.
Good information.. I would have never known this information had i not decided to pursue medical billing and coding. The ehr and all that that entails is interesting, i never knew that physicians had documentation requirements. Apparently they didn’t either lol
Thank you for watching and for your comment.
Doctor, Can you tell me if I want to sue the Hospital on grounds that the electronic records purported to have been transcribed by an outside company were not transcribed by the outside company till a month later, do I file a case in the State or the Federal Court. It is a HIPAA matter? The records eliminated all ER records and put in a paragraph of a drug that was given. The particular drug was given at a later stage causing overdose and damage to the Brain (as told to me by the Neuro of the ER ). The records were given to our attorney and were believed by the law firm to be accurate. Pro se in New Jersey.
Good question. I do not know.
I am confused. This detail you speak of that is required to support billing - do you mean both with insurance companies and Medicare? I never see this information in a treatment note. Is it someplace else??
Unfortunately, current state EMR's are being built primarily for data collection, not for provider ease of use or improved quality of care. This disparity is giving rise to career opportunities to those in the CDI field where the golden nuggets, as you say, can be gleaned @ the pre-visit stage and prompted to the providers for capture @ the point of care.
Thank you for watching and sharing your perspective.
SCRs are for data sharing and things like COVID Programmes
You have a primary record and SCRs can be used for anything regardless what they tell you - OPT OUT
I can not get into this to find
My results of a Biopsy I have had there.
As you know, this is just scratching the surface or our inefficient and gaping deficient EMR/EHR platforms. Here are a few of my observations as an QI RN Clinical Compliance Auditor that spent 10 years in the field auditing and training Medical Practices for Health Plans and the State of CA as a Certified Master Trainer.
#1 Accurate Information loaded into the EHR is critical and when Practices receive Health Plan eligibility list "E-List" these are chronically wrong. Keep in mind the Practices are responsible to engage these patients for preventive screening and disease management in some type of shared risk agreement with the HP/IPA and Practice contract. Therefore that Practice is ultimately responsible for each encounter and to complete these encounters in a timely and comprehensive manner.
#2 The paperwork that is given to that patient as they sit in the waiting room pre-visit is often several pages of Information including a listing of multiple medical problems,SDOH questions , past medical treatments,ADL questions and multiple other forms needed to have signed for the billing and treatment consent. Let's be honest, we know the Patient has limited understanding on what they’re reading and "checking the boxes" and signing. Furthermore why couldn’t much of this Information come from there previous insurance and previous PCP? The company we are working with has streamlined and increased the efficiency of this specific process in the comfort of that patient home but I'm not here to promote myself. Just pointing out this is a huge barrier to capturing a comprehensive visit and render proper treatments and the billing effectiveness.
#3 Our laws have mandated that EHR's be able to be migrated to other EHR's and be part of a Health Information Exchange "HIE" Furthermore Practices are required to have "Patients Portals" to allow patients to have access to their EHR's. The compliance of the above is minimal.
#4 The "Follow Up" Most visits require some f/u. Whether it's a medication a referral to a specialist or multiple other reasons. The bottom line is less than 50% of these f/u visits are completed and very minimal efforts are done to follow through and close the loop.
We know the fact that 85% of MediCare eligible aged (65+) have at least 1 chronic disease. In contrast less that 10% of these patients that are MEMBERS of MediCare Advantage Health Plans are in any type of Chronic Care Management Program. In some Plans less than 5%.
Less face it our system is complicated and fragmented and somehow the Health Industry operates in the 80s-90's, uses FAX machines and is in denial of the SaaS platforms and RPM programs that would increase interoperability. Yes I'm bias towards "management of care" in-between' office visits with Telehealth and RPM but I honestly don’t see any other Solutions
Sorry so long of a reply
Thank you for watching and for your thoughtful comment.
Is kind of obvious this software are made using the input of epidemiologist and administrators... But none of the ones thst have to use it.
True. Thank you for your comment.
I always have a problem with these software and administrators at large. Some of them are so clueless about what goes on with the people who are actually using these tools. Sometimes, the disconnect is irritating. 😮
This video is fantastic!
Thank you for your feedback.
Doctors notes are exactly the problem. I pray every time I change doctors that the new one will ONLY look at labs and imagining. I actually ask the doctor to please not read notes but only review labs. But they won't do that because they don't want to look at the same labs and document a different diagnosis. Not because they aren't sure but because they don't want to document errors of each other... You make excuses for each other all the time and people die because of it.
And I am over the excuses I hear all the time:
Doctors are over worked.
Doctors are taught to prescribe...
Doctors aren't taught...
So a "doctor" stands before me with at least 8yrs of study of the human body and you don't have a clue how to fuel it or what to do if you can't write a prescription...
Patients need to be more informed and hold their doctor accountable...
You don't get to tell me "I must" and when it goes bad tell me "I didn't know"...
Thank you for sharing your thoughts.
I stopped what I was doing to comment and subscribe. I see patients notes larger than textbooks. I can bet that something important will be missed. Even control F to find things is not helpful. It’s such a mess.
Agreed. Thank you for sharing your perspective.
Has this problem been solved yet or still and issue ?
Still a problem. Thank you for watching.
@@ahealthcarez may I contact you directly, my business partner and I are planning a startup around improving medical records.
This video needs better subtitles.
Thank you for your feedback.
@@ahealthcarez Thank you for being open to feedback.
Are there smart text features where commonly used phrases can be selected in EHR? Just curious if custom features exist too. My team is currently building an app and we were asked to add copy to clipboard feature so they can paste in EHR? 😅
AI can help in scanning volumes of data and pluck out "golden nuggets" for billing
Thank you for your comment.
Actually, I wonder if ChatGPT would assist by condensing it into a super short summary....@@ahealthcarez
I know this to be so..
Thank you for watching and leaving a comment.
Its technically called a metric shit ton
Thank you for watching and for your comment.
That means the lecture current, if he says by 2022 meanwhile we are in 2023. So what's the percentage of copy and paste now.