It’s not the sole reason but given that billing is based on it (ICD codes). I can see your point.
I remember the bean counters from the hospital going over with scribes and doctors on how to “properly” document all the necessary elements to bill for a procedure. All of it was very very boring.
“We can bill for ED physician prelim reads of radiology studies but it needs to have at least 3 or more findings documented. “
So let’s say a an ed physician orders a chest xray to r/o pneumonia vs bronchitis. Have to document in chart something like: “3 view chest xray; no infiltrates, no pleural effusion, no pneumothorax; received by X doctor”
In reality, most doctors would just put “reviewed 3v cxr, no infiltrates”. No need to document negative findings that contribute nothing.
Prior to EMRs, hand written notes and charts were absolutely god awful to read. Physician and nurse short hand is not standardized. Plus some doctors handwriting is just atrocious.
EMRs helped standardize communication between multiple parties (both medical and non-medical). Like others have mentioned, it could have been a way to track standards of care across multiple hospitals or across the US. Unfortunately with the gold rush to get a product out there, all we got was 9-10 different proprietary EMR systems that do not have interoperability.
CT scan performed in Virginia and needs to get reviewed by doctor in California? The hardcopy of the images uses some proprietary viewer that is only accessible within the same system the Virginia hospital used. I remember a few cases of this when we had transfers from out of state. Either hospital physician gets their own additional scan and official read or waits for physical images from other hospital to view. I think in a CT this can be hundreds of images/slices. (Don’t quote me on this, this was a decade ago lol)
I remember the bean counters from the hospital going over with scribes and doctors on how to “properly” document all the necessary elements to bill for a procedure. All of it was very very boring.
“We can bill for ED physician prelim reads of radiology studies but it needs to have at least 3 or more findings documented. “
So let’s say a an ed physician orders a chest xray to r/o pneumonia vs bronchitis. Have to document in chart something like: “3 view chest xray; no infiltrates, no pleural effusion, no pneumothorax; received by X doctor”
In reality, most doctors would just put “reviewed 3v cxr, no infiltrates”. No need to document negative findings that contribute nothing.
Prior to EMRs, hand written notes and charts were absolutely god awful to read. Physician and nurse short hand is not standardized. Plus some doctors handwriting is just atrocious.
EMRs helped standardize communication between multiple parties (both medical and non-medical). Like others have mentioned, it could have been a way to track standards of care across multiple hospitals or across the US. Unfortunately with the gold rush to get a product out there, all we got was 9-10 different proprietary EMR systems that do not have interoperability.
CT scan performed in Virginia and needs to get reviewed by doctor in California? The hardcopy of the images uses some proprietary viewer that is only accessible within the same system the Virginia hospital used. I remember a few cases of this when we had transfers from out of state. Either hospital physician gets their own additional scan and official read or waits for physical images from other hospital to view. I think in a CT this can be hundreds of images/slices. (Don’t quote me on this, this was a decade ago lol)