Only 7 percent of structured EHR data in a typical patient note is required in order to meet Meaningful Use, according to a new study by clinical documentation vendor WebChartMD. The percentage only slightly rose to 9% when lab data was present. The study analyzed one hundred de-identified orthopedic and cardiovascular patient notes obtained from MTSamples.com revealing how EHRs can place excessive data entry burden on physicians.
The report found as much as 91 to 93 percent of data typically captured within EHRs in a structured format (e.g. point-and-click templates and drop-down boxes) could instead be captured as unstructured data (e.g. dictation and transcription, or free-text entry) and still meet Meaningful Use requirements.
“This study is especially relevant for physicians frustrated by the negative impact EHRs can have on their patient interactions and their productivity,” said Mark Christensen, WebChartMD’s CEO. “Physicians are often asked to capture more data in a structured format then Meaningful Use requires.”
Data required to be structured for Meaningful Use requirements are:
- demographics (preferred language, sex, race/ethnicity, date of birth)
- vital signs (height, weight, blood pressure, BMI)
- smoking status
- problem list
- medication list
- medication allergies
- lab tests/values
- minimum of one Family History entry
According to Elisabeth Myers, Policy and Outreach Lead at the CMS, much of the data routinely documented as part of the patient encounter – such as the History of Present Illness, Assessment, and Plan, to name a few key document sections – can be incorporated into the patient record within the EHR as unstructured data without in any way preventing the physician and clinic from meeting Meaningful Use.
“Too many physicians struggle with their EHRs when they simply don’t need to be,” said Christensen. “A greater use of dictation and transcription could represent a faster and easier means of documenting large portions of their patient encounters.”
