My EHR Tells Me I’m a Bad Doctor.

I’ve written before about our EHR and all the the things that I really like about it. Add to that list the fact that we can now get incentive payments from Medicare (or Medicaid) for buying and using an EHR (we were early adopters of the technology before the current incentives came out). But in order to qualify as an electronic health record in the government’s eyes, the federal government determined that everyone’s systems must meet certain minimum functionality requirements, what they call “meaningful use”. This is where things are getting tricky. . . because my beloved EHR is telling me that my medical records are are not meaningfully useful, and in fact are meaninglessly useful, or meaningfully useless, one or the other, or perhaps both.
As if that was not enough of a slap in the face after all the love and adoration I’ve showered upon the system, there’s this bitter morsel. I’m being told that the manner in which I’ve been deficient is in the department of documentation of smoking. Can you believe that? Smoking! Me! The super-anti-smoking guy! The one who wrote this article. And then the other one. Plus, remember that other one? Seriously?
Could I truly be deficient in my smoking documentation? Refusing to believe such blasphemy, I delved into the medical records. No, see, there it is? Right there.  Under HPI, “patient has no history of smoke exposure”. And there again, in the next chart, more extensive smoking data meticulously typed into the history. I knew that I was documenting this stuff. What could the problem possibly be? Continue reading “My EHR Tells Me I’m a Bad Doctor.”