Rethinking clinical documentation for the EHR era

'The voices of regulation, defensive medicine, billing and quality measure reporting have been so loud that the primary reason for documentation has been ignored.'
By Sherree Geyer
12:15 PM

Shaun Grannis, MD, can relate to the recent study in the Annals of Internal Medicine showing that physicians spend 37 percent of their time on clinical documentation in their electronic health records.

"Eight years ago when I was seeing patients, I would dictate for 90 seconds after every patient in free text and communicate all care provided," said Grannis, interim director of the Center for Biomedical Informatics at the Indianapolis-based Regenstrief Institute.

"Today, I fill out a five-page template for a sore throat that no one wants to read, with details that providers often miss," he said.

Peter Basch, MD, feels his pain.

"Our concern is that the voices of regulation, defensive medicine, billing and quality measure reporting have been so loud that the primary reason for documentation has been ignored," said Basch, senior director IT quality and safety, research and national health IT policy at MedStar Health in Washington.

[Also: Is all that EHR documentation causing physician burnout?]

"The purpose of clinical documentation is to document what happened in an efficient, effective manner," he said. "Documentation should remind us, when we next see the patient, what we saw, thought and did."

Basch is one of the authors of "Clinical Documentation in the 21st Century," for the American College of Physicians.

"The Medical Informatics Committee for the ACP became interested in a position paper as a response to clinical documentation in the EHR, which I can summarize as 'copy and paste,' occurring frequently," he said.

"Copy-and-paste or use of macros becomes problematic when documentation shortcuts don't reflect the history and/or physical exam of the patient," Basch explained. "If copy-and-paste creates incorrect documentation, the next provider might be misled and reach inappropriate diagnostic or treatment decisions.

"The line is fully crossed into fraud when copy-and-paste of complete notes is used for different patients and, in the most egregious cases, to bill for patients never seen," he explained.

Lesley Kadlec, director of the American Health Information Management Association, agrees that "the goal of the patient health record is to tell the patient story and technology should facilitate that process."

She ticks off the reasons clinical documentation contributes to provider stress.

"One example is voice recognition technology or text entry as a replacement for traditional dictation and transcription. While transcription costs may decrease, time spent by physicians learning the voice technology, editing notes or creating documents using text entry increases."

Kadlec adds that, "design and user-friendliness of an EHR system greatly impact clinical burnout.

"If it takes too long to enter data or search for items in lengthy drop-down menu; that will seem burdensome to clinicians who wants to focus on the patient" said Kadlec, who thinks "all areas of the patient encounter need to be mapped, not just the clinical portion."

[Also: One hospital's new approach to clinical documentation]

According to the ACP position paper, "cooperation is needed among industry healthcare providers, systems, government and insurers to improve documentation. We must work together to fundamentally change the EHR from a passive recipient of information to an active virtual care team member."

Kadlec agrees. "IT and clinicians should work collaboratively to design and customize an EHR that best meets the needs of the organization and tells the patient story," she said.

"Regular feedback is important. Sharing what works and what doesn't work and then re-designing the technology and processes that improve workflow should be done regularly. The EHR should be an evolving work-in-progress, not a once-and-done project," said Kadlec – who suggested "a combination of structured (standardized) data, free text and voice dictation offers the best range of options in capturing the clinical picture and telling the patient story."

However, the ACP position paper notes that "structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting."

"We believe in standards that support operability and interoperability of structured data," said Basch. "We also believe that not all information should be structured as that can destroy context and narrative and distort meaning."

[Also: Florida Hospital reaps $72.5 million from clinical documentation improvement, achieves ICD-10 compliance]

He tells IT developers to "build software to support the business of medicine."

After all, physicians won't buy EHRs that don't support coding and other reporting requirements, said Basch. "We hope these coding and regulatory requirements will permit some flexibility where the ability to appropriately act upon informational views becomes the market differentiator, not checkboxes to satisfy regulatory compliance."

Despite the rapid digitization of healthcare over the past decade or so, it's worth remembering that "we're in the early days of EHR," said Grannis, who predicts that "what will happen in 20 years is what I used to do eight years ago – walk into a room in my clinic and interact with the patient, human to human.

"We will have solved the technology problems, the voice recognition and (artificial intelligence) problems," he said. "We're getting better at recognizing this is fundamentally not just a business and financial decision, but a care decision. Ensure that providers at all levels – from physicians to nurses to technicians in this workflow – evaluate each project."

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