HIT Policy Committee split over Stage 2 proposal

Do doctors have to be typists?

WASHINGTON – 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.

At a May 2 meeting, the HIT Policy Committee was divided over a proposal 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. According to Paul Tang, MD, vice chair of the HIT Policy Committee, decision support, which helps to prevent medical errors, is “the single most important objective of the entire EHR incentive program.”

Most electronic health record systems only show decision support once, as the computerized physician order entry, or CPOE, is typed into a system, Tang said. 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.

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.

Gayle Harrell, a Republican state representative from Florida, said the requirement should fall where the liability falls. “Liability is the issue,” she said. “It’s going to be difficult to determine who’s the typist.”

Neil Calman, MD, president and CEO of the Institute for Family Health, felt decision support should not be compromised. If a physician doesn’t see the decision support, what good is it? “As long as the decision support appears at the time of authorization, the person who enters the order isn’t really that important,” he said.

“I strongly disagree with that,” said David Bates, MD, chief of research for the division of general and internal medicine and primary care at Brigham and Women’s Hospital. “If physicians are to see the decision support, they have to see it when they type in the order, he said. “I’ve looked at a lot of different systems, all of them deliver decision support at the time that you’re actually entering the order.”