There's a snag in the proposed meaningful use Stage 2 rule, and it concerns whether or not doctors need to be good at typing. Depending on how the final requirements for Stage 2 play out, they might have to be.
The HIT Policy Committee on Wednesday was divided over a measure in the Stage 2 rule that would allow licensed professionals or scribes to enter data into a patient’s electronic health record on behalf of a doctor.
The difficulty is this: If a doctor doesn’t enter the order, he or she will not be able to see the decision support built into the EHR system that appears at that time. Decision support is supposed to help with the prevention of medical errors and is, according to federal officials, one of the reasons for the EHR incentive program in the first place.
Most electronic health record systems only show decision support once, as the computerized physician order entry, or CPOE, is typed into a system, according to Paul Tang, MD, chief innovation and technology officer at the Palo Alto Medical Foundation and vice chair of the HIT Policy Committee. The problem is, most doctors do not type in their own orders. Nurses often enter medication orders or clerical persons type in hand written physicians’ orders, later to be “signed off on” – or approved on the computer – by the physician, often in groups of multiple orders at the end of the day.
As the proposal stands now, the physician is required to use his or her personal log-on to open the record, and he or she is the person responsible for the electronic record. The physician is also responsible for approving any information entered by someone representing him or her in a clerical sense. If doctors want to see decision support, which includes warnings about dangerous drug interactions and other health preventative and safety warnings, then the doctor must be the one to type in the information.
Some members of the committee felt the rule was never intended to make doctors into typists. And even if they are good typists, they shouldn't be required to spend their time doing it. It prescribes too much for a doctors’ workflow, and is not what the proposal framers intended.
A serious discussion arose over the CPOE subject, scribes and decision support – labeled by Tang as “the single most important objective of the entire EHR incentive program.”
Last month, the committee discussed if there were other ways a clinician could have something recorded, then take responsibility for it. A physician might want to have a licensed professional enter the CPOE and then have someone else do the clerical task of entering the progress notes. Tang urged the committee to be more specific about who can enter non-CPOE entries.
Some members of the committee were in favor of scribes entering non-CPOEs, some were against, with the major consensus among the group that the physician is ultimately responsible for what is recorded.