New Recommendations Address EHR Clinical Documentation

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New Recommendations Address EHR Clinical Documentation
New Recommendations Address EHR Clinical Documentation

The American College of Physicians has published a policy position paper that provides recommendations geared toward improving the quality of electronic health record (EHR) clinical documentation in effort to improve patient care.

The paper was published in the Annals of Internal Medicine.

“Our paper attempts to present what documentation was supposed to enable an effective and efficient record that captures the essence of what was said, found, thought about and done; what has influenced clinical documentation over the years; and recommendations for both clinical documentation guidance and EHR design,” Peter Basch, MD, FACP, paper coauthor, told Endocrinology Advisor.

According to Dr. Basch, who is Medical Director of Ambulatory EHR and Health IT Policy at MedStar Health and chair of the Medical Informatics Committee for the American College of Physicians, there is widespread dissatisfaction with the quality of today's clinical documentation, particularly EHR documentation. 

“Clinicians blame their EHRs for taking what took years of training to do well — the production of concise restatements of relevant history, findings, assessment and plan (albeit often illegible) — and morphing these into excessively verbose and inelegant (albeit legible) notes,” Dr. Basch said.

This led Dr. Basch, Thomson Kuhn, MA, and colleagues from the Medical Informatics Committee to undertake a review that aimed to clarify the broad range of complex and interrelated issues surrounding clinical documentation and provide a path forward.

In the paper, the authors wrote that EHRs should be leveraged for what they can do to improve care and documentation. These include “displaying prior information that shows historical information in rich context; supporting critical thinking; enabling efficient and effective documentation; and supporting appropriate and secure sharing of useful and usable information with others, including patients, families and caregivers,” they wrote. “These features are unlikely to be optimized as long as the format and content of clinical documentation are primarily based on coding and other regulatory requirements.”

Dr. Basch added that while clinicians continue to struggle with EHR usability and the Meaningful Use program, at least part of the solution is to address not only EHR software design and maturity but also several other drivers, including guidelines for evaluation and management coding documentation. 

“We also believe that neither clinicians nor patients are well served by abandoning appropriately used techniques that enhance consistency of standard medical descriptions; and instead, as a response to fear of failing a documentation audit, substitute appropriate use of standardized medical descriptions with ‘forced uniqueness,'” Dr. Basch said.

In an accompanying editorial, Thomas D. Sequist, MD, MPH, of Brigham and Women's Hospital and Harvard Medical School, wrote that to achieve the authors' goal would require a vision for clinical documentation that moves beyond the static clinical note physicians create during an office visit or hospital stay.

“Instead, we must address three questions to realize a future of ‘high-value' clinical documentation,” he wrote. “First, who should enter information into the EHR, and when should they enter it? Second, what information should be entered? Finally, how can we effectively integrate the information in the EHR into comprehensive patient care?”

Sequist added that the power of EHR clinical documentation to improve the quality of patient care has not yet been fully harnessed.

“The true power of EHRs may be in moving from documenting isolated clinical transactions to describing whole-patient care from multiple stakeholder viewpoints,” he wrote. “Ideally, this process will shift providers from perceiving electronic clinical documentation as a distraction to high-quality patient care to seeing it as a core component of such care.”

References

  1. Kuhn T et al. Ann Intern Med. 2015;doi:10.7326/M14-2128.
  2. Sequist TD. Ann Intern Med. 2015;doi:10.7326/M14-2913.
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