The purpose of clinical documentation is to efficiently communicate critical data to peers in a readable fashion while meeting compliance and billing requirements. This documentation should not represent a data dump.
Physicians continually increase our dependence on technology as the digital age deluges us with data. Accessing the right information at the right time is essential to providing appropriate care. The tsunami of new evidence necessitates clinical decision support, yet we want to be bombarded with a plethora of irrelevant alerts. Creating a system that allows for quality care should be the mission of any electronic health system.
Is technology the solution or the problem? Physicians survey shows almost half believe it is more of a problem. Many of these physicians are bombastic whiners. Ask them if they want to go back to paper, and they will look aghast. Together we need to work on actionable solutions.
Team-based care should mean physicians, nurses, appropriate therapists — not coders and insurance companies. Clinical notes should be a collaborative effort, not a repetitive regurgitation replete with copy and waste.
Progress notes on paper were often scribbled and illegible. yet provided a clue as to what the physician was thinking. Today’s notes are illegible in a different way. Distinguishing copied forward text from automagically added templates from thoughtfully typed thoughts is difficult. Hundreds of words exist where once “ No 𝛥, VSS, ↑ ambulation, home tomorrow” sufficed. That note today would include an abundance of repetitive data, flow sheets, and labs. The advent of tools to add clinical data to our notes has created a monster called “note bloat.”
A physician, helping implement an electronic health record the Netherlands, demonstrated functionality that allows the clinician to click boxes to generate a prose physical exam. The Dutchman said, “I don’t understand.” As the American started again to demonstrate clicking boxes, he was interrupted: “I understand what your system does, but why? I just write ‘Normal Exam.’ Don’t you know what that means.”
Technical advances address the redundant data, not the root cause. Functionality exists that shades copied portions of the note. This tool spares us wading through gibberish and redundancy. Many find workarounds to communicate. The data exists in other parts of the chart and is better viewed in context.
As a discipline, the notion that if it isn’t documented in a progress note, it wasn’t reviewed or didn’t happen needs to be dispelled. Audit trails, if not “mark as reviewed” buttons are more than sufficient to prove the appropriate data was put before the provider’s eyes.
Are there particular recommendations regarding “the purpose of notes” that could be addressed to the EHR WG (as we attempt to describe standards for EHR system functionality), to regulators (in terms of their requirements for data capture and reporting), to payers (in terms of their requirements for payment: pre-authorization, claims, claims substantiation), to providers (in terms of their operations and policies), to EHR/PHR/HIT system developers (tying back into the EHR WG effort to describe EHR system functionality), to EHR system implementers (in terms of how best to configure systems, information flows, data capture and review, reporting), to professional societies (in terms of their specialty focus/guidance), to consultants …?
Context-based or review based approach; not a documentation-based paradigm. Improving the usability of documentation.
Rules themselves need to be changed. Address the framework that has created the rules under which we operate today. The clinician note should be distinct from the coding and compliance piece, with a focus on the patient narrative, pertinent exam findings, and medical decision making. Our education has taught us how to extract the pertinent narrative from the patient and to execute medical decision making. This needs to be in our note. Time spent reviewing normal data such as labs and imaging is captured by the system and serves no purpose being reiterated. The EHR can provide a report that Dr. X reviewed labs/imaging/old notes and spent a total of x minutes in the chart including prior to, during and after the visit. Audit trails, not “mark as reviewed” buttons are more than sufficient to prove the appropriate data was put before the provider’s eyes. Extracting useful information from the note is far more efficient when not obscured by useless information.
We must not perpetuate a culture of overwrought and overworked providers entering inaccessible information which makes getting useful information out impossible. The solutions lie not only in our own workflows and documentation habits but also in our willingness to participate in national efforts to change billing and compliance rules.
The U.S. Department of Health and Human Services (HHS) issued a draft strategy designed to help reduce administrative and regulatory burden on clinicians caused by the use of health information technology (health IT) such as electronic health records (EHRs). They have asked for public comment, and I encourage you to let your voice be heard. The public comment period on the draft Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs ends on Monday January 28, 2019 at 11:59:59 PM ET.
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