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New EMR Mandate "meaningful use" - Canadice

Posted: Apr 29, 2011

I am jujst starting to research this issue and wondering if anyone here has any information on how this affects us as MTs. The EMR I am currently working in is Medent and they are trying to comply with this new mandate. For me this means the docs point and click on the assessment/diagnosis. Then I type the dictated Plan/Comments. both these fields are printed out for the patients in compliance with the 'meaningful use" which says that the patient will have to be provided with an EMR print out within 3 days of office visit. For this practice, they like me to use as many acronyms and abbreviations as possible and so my question is where I will need to eliminate acronyms and abbreviations for cater to patient's understanding of said printout.

I would appreciate any thoughts on this issue. Thanks much ;)

Interesting question. I'm not hit with this problem yet, but - the standard grammatical practice

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has always been to use the full form on introduction of the term, only after that using short forms. Knowing lay people are reading, I'd follow the initial term with the short form in parentheses to help them further. Plus, of course, the long form should be used in diagnoses, etc. Good organization and specific headers, of course, are always important factors in conveying information meaningfully.

Since you sound at least somewhat concerned about patient understanding, beyond just legal compliance, I can tell you with weary authority (used to send out a dozen or two custom letters every day to business professionals) that many, many people do not take in information well in written form. I can't even imagine how many times the head of a company or one of his department heads would call me to explain what a simple 1/2 page letter was asking for. After "as we discussed today" etc., I learned to drop and center any request or key phrase, like

"Please sign and return the enclosed X form in the enclosed envelope."

And then I would highlight that with a yellow highlighter! It helped cut the number of "what is this?" calls considerably, but I still got plenty anyway.

BTW, since I was dealing with valuable, lucrative clients, these letters ALWAYS followed personal phone calls discussing everything and explaining that the form discusse, or written confirmation of whatever, was on its way. Sigh...

In any case, although I'm sure meaningful use will be satisfied by much less, generally speaking, you simply cannot go overboard in trying to make written communications as simple and easy to understand as possible.

You would need to ask your supervisor or - sm

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whoever. If they want everything abbreviated, then that is what you have to do.

OP may be an IC, without one. Also, not all places are - are on top of all this and may

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need suggestions. An IC should have an independent grasp of at very least the more important regulations and their implementation. OP is obviously moving to get on top of this issue and poses a good question. This isn't exactly a hangout for IT legal eagles, though.

Whether the OP is an IC or not, she needs - sm

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clarification from the client on what and when to use or not use abbreviations.

Abbreviations.... - MT

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This is something the Society for Participatory Medicine is working on now, to develop a glossary for patients to understand all of those abbreviations. They are a pretty interesting patient advocacy group, advocating for patient involvement in their health care. (And if I'm not supposed to post names of organizations here, I apologize. I figured since AHDI is mentioned maybe this one could be as well.) They just started this project this week through their blog.

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