This article is more than 5 years old. Information may no longer be current.
How is your medical charting?
Click Here to Manage Email Alerts
My role as the chief medical officer of an eye and vision HMO provides me with a unique window into the medical charting of eye doctors. In the managed care world, any time a patient files a grievance with the health plan, the medical record is requested, and the chart is reviewed. If the chart is substandard, the provider must submit 10 charts for review. Depending on the health plan, these reviews may be executed by a medical doctor, a nurse or, in the case of eye and vision care, an optometrist. In our company, optometrists perform all of the chart reviews.
In spite of optometrists being licensed to provide medical care in all 50 states, of ophthalmologists being trained in a medical environment, of ophthalmic electronic health records (EHR) being widely available, of sizable government stimuli being offered for the meaningful use of EHR, of health plans (like mine) requiring providers to send charts related to grievances, the eye care charts that we review are, for the most part very weak. It is almost comical to read a grievance that says: “The doctor did not spend 5 minutes with me” and then look at the chart and realize that the doctor must have spent 4 of those 5 minutes chatting about the weather!
Medical charting is a critical part of health care reform. When I started this blog feature last summer, I dedicated the first few installments to specific elements of the primary medical care eye examination. I urge you to look back at: Using the review of systems in optometric practice, The importance of medicine reconciliation and The ‘doctoring’ of the eye examination. These elements change the nature of the eye examination and are the first steps of assuring optometry’s appropriate role in health care reform.
Several companies organized by some of the leaders in optometry are now looking at the second step for optometry on the path to reform. These companies are looking to take the medical data from our EHR and place it in a database or registry to be able to transfer it to primary care physicians, hospital systems and health plans. These systems will also be able to gather critical data from these systems and transfer it back to us to better care for our patients.
There will be practices that are ready for this step, but that number will be very small. The keys to optometry’s success in health care reform are in our large numbers and in our convenient access to a large population of people. We are the providers in the small towns, in the shopping malls and on the street corners. We have short waits to get an appointment, short waits in the waiting room and evening and Saturday hours. These are the things that define “primary care.”
The next step involves analyzing our clinical data to develop normative outcomes data and best practice procedures. In the long-term scheme of the reform movement, providers will not be paid per service but rather for successful outcomes and overall wellness of our patients. These are radical concepts and are way down the road for implementation.
I believe that the ophthalmic community is not ready for step two. Frankly, other than in some unique academic communities, the medical community is not ready for step two. This is part of the reason that ICD-10 has been delayed, and you have heard my opinion on that (Welcome relief from ICD-10).
So, we need to get serious about step one. Optometrists need to convert their examination and documentation to the primary medical model. Conversion to EHR will help, but it is not the whole answer. EHRs that allow the doctors to “hit the defaults” and bring in a lot of cloned language do not make for a thoughtful medical record.
Doctors are always telling me, “What was in the chart is not what happened during the exam.” That is never an acceptable response. Your chart must reflect exactly what happened in the examination. It is a legal document and is the only record of the encounter that will count. At some point it will be converted into your patient’s comprehensive health record that will follow them throughout their life. Let’s use our medical charts to start down that road toward better health care for all.