Posted by: Tony Shannon | January 30, 2015

Healthcare Change: Clinical Documentation in the 21st Century

Every so often an article comes across your desk that is worth sharing more widely. Of course in this day and age news doesn’t hit your desk as much as reach your smartphone and via a tweet.

So thanks to a recent tweet from @IanMcNicoll, I came across an article that was worth a mention.

Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians
Thomson Kuhn, MA; Peter Basch, MD; Michael Barr, MD, MBA; Thomas Yackel, MD, MPH, MS, for the Medical Informatics Committee of the American College of Physicians*
Ann Intern Med. Published online 13 January 2015 doi:10.7326/M14-2128

Now policy statements aren’t usually particularly interesting but I liked the 21st Century long view this paper was taking from the start. What may seem like a very niche subject goes to the heart of the challenge that 21st Century Healthcare faces. That is with regards to my own work across healthcare/ process improvement/ information technology this policy paper has enough good material that it seemed worthy of sharing and bringing to other people’s attention…

It’s a pretty lengthy paper which suggests its unlikely to get wide readership, so to be able to share the essence of it more widely I’ve culled/cut/moved quite a bit to emphasise the key points and am otherwise replaying them verbatim here (so clearly the rest of the material remains the copyright of the ACP etc) from their (thankfully free) online article ;

On the Background to “Clinical Documentation”;

“Observe, record, tabulate, communicate.—Sir William Osler (1849–1919)”

“The medical record was first used by physicians to record their findings and actions and as a vehicle to communicate with other physicians who might care for the patient in the future. Physician notes were concise, were handwritten or dictated, varied in length and detail, and typically reflected the personality and style of the physician.
.. This was the documentation style of physicians until the early 20th century, when leading hospitals began to require structure and the use of forms to organize what had been essentially free-form notes in order to perform analyses of their medical records and improve quality. “

“Over time, clinical documentation has evolved in response to other pressures outside of the desire to improve systems of care in hospitals and care for individual patients. The medical record also became an essential legal document with requirements for nonmodification and retention, a vehicle for education of medical students and trainees, and the defined work product for which physicians were paid. “

“In 1968, Lawrence L. Weed, MD, published a seminal article on the subject of clinical documentation, “Medical Records that Guide and Teach” (8). Weed observed then (decades before the emergence of the EHR as a tool outside of select academic centers and computer laboratories) that paper-based clinical documentation was confusing, scattered, repetitious, and sometimes even directly responsible for diagnostic and therapy errors. His response was to argue for a new style of documentation that focused on problems and how they should be managed and documented “:

“Weed’s work was widely read and appreciated and, by the mid-1970s, became the standard by which American medical students were taught to document.”

On “Evolving Purposes and Drivers of Clinical Documentation”;

“Increasing Demands for Structured Data”

“As with the rise of the quality movement in hospitals in the early 1900s, the current shift from volume-based to value-based payment models is driving the need for more structured data. “

“The laudable goal is to be able to extract data automatically from patient records, compile the data into reports, and export them with the click of a button. This process, if it worked well, would be far better than the current process of manual chart abstraction; additional data entry at the point of care; “
“Many “e-measures” are in the early stages of development and thus have not been fully implemented in EHR systems. These measures often require physicians and other health care professionals to enter additional data into the appropriately structured fields. It is unlikely that entering accurate and complete data into structured fields will become a high priority unless doing so becomes easier and more efficient than it typically is.”

On “Opportunities and Challenges of Clinical Documentation With EHRs”

“Electronic health record documentation is always legible; is always available anytime and anywhere, except during system downtime; and can be accessed by multiple persons, including patients, at the same time in different locations. However, legibility and availability do not necessarily result in efficiency and usability”.

“The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.”

“Data Display”

“A common complaint from users is that EHR interfaces are unnecessarily cluttered and require too much navigation for too little value.”

“Data Entry”

“An examination of paper-based records from most physicians clearly shows that the nature of medical documentation—other than the patient narrative—tends to be controlled and standardized with respect to documenting normal or expected findings. One-click templates and macros to generate findings from a normal physical examination or review of systems are time-saving functions that replicate what physicians would otherwise have to handwrite in paper-based records and should be acceptable as long as the final, signed documentation accurately reflects what occurred during the patient–physician encounter.”

“Capture and Use of Structured Data”

“For many types of information, properly formatted structured data are of enormous value and greatly aid clinical care, especially through well-designed CDS and flow charts that highlight opportunities for improving the health of individuals and populations. However, not all clinical data lend themselves to structured documentation.”

“The ideal note would facilitate hybrid documentation by allowing physicians to efficiently capture the patient narrative and supplement it with context-sensitive, template-driven data that enhance rather than detract from the clinical record’s relevance as a communication tool. Furthermore, the EHR should account for the concept of synthesis of information over time.”

“Policy Recommendations for Clinical Documentation

“Clinical documentation, whether on paper or in an EHR and regardless of other drivers, should strive to effectively and efficiently serve the purposes of documentation as described by Sir William Osler: “record, tabulate, communicate.”

“The College strongly supports the use of EHRs in clinical medicine on the basis of the potential to improve quality of care provided to individuals and populations.
The College strongly supports the use of new capabilities within EHRs and other health information technology to enhance the efficiency and accuracy of documentation as well as the transformation of the medical record from predominantly a reflector of gathered information to a dynamic, team-oriented communication tool that serves the entire care team, including patients and families. To these ends, the College offers the following policy recommendations.”

“The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.”

“The primary purpose of clinical documentation is to facilitate excellent care for patients. Whenever possible, documentation for other purposes should be generated as a by-product of care delivery rather than requiring additional data entry unrelated to care delivery.”

“The EHR should facilitate thoughtful review of previously documented clinical information. Ready review of prior relevant information, such as longitudinal history and care plans as well as prior physical examination findings, may be valuable in improving the completeness of documentation as well as establishing context.”

“The clinical record should include the patient’s story in as much detail as is required to retell the story.”

“To preserve the integrity of the patient narrative, requirements for capture of structured data should be kept to a minimum. Structured data should never take the place of narrative comments.”

“Structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting.”

“Ultimately, billing requirements should be adjusted to accept accurate documentation generated for clinical purposes. “

“As value-based care and accountable care models grow, the primary purpose of the EHR should remain the facilitation of seamless patient care to improve outcomes while contributing to data collection that supports necessary analyses.”

“To the extent possible, metrics designed to support analyses of quality and value should leverage data collected in the usual course of patient care, with appropriate attention to privacy and other ethical concerns, rather than requiring clinicians to take extra time to collect structured data not essential to patient care. When data are required beyond those that are generated as a consequence of care delivery, clinicians, practices, and health care systems should be compensated for time spent collecting these additional data.”

“Patient access to progress notes, as well as the rest of their medical records, may offer a way to improve both patient engagement and quality of care.”

“Policy Recommendations for EHR System Design to Support 21st-Century Clinical Documentation”

“EHR developers need to optimize EHR systems to facilitate longitudinal care delivery as well as care that involves teams of clinicians and patients that are managed over time.”

“Important elements of documentation, such as the patient narrative and differential diagnosis, cannot be lost as a consequence of overstructuring or underdesigning the user interface . The needs of medical practice should drive the development of EHRs and not the reverse “.

“Clinical documentation in EHR systems must support clinicians’ cognitive processes during the documentation process.”

“Electronic health record systems must enable collection of data and interpretation of information from multiple sources by clinicians as appropriate and necessary, including nuanced medical discourse, structured items, and data captured in other systems and devices “.

“Summary”

“Electronic health records should be leveraged for what they can do to improve care and documentation, including effectively 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. “

“Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach, to the detriment of patient care.”

“Cooperation is needed among industry health care providers, health care systems, government, and insurers to continue to improve the documentation. We must work together to fundamentally change the EHR from a passive recipient of information to an active virtual care team member.”

For any further detail I can commend the full text of this article here.

Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians
Thomson Kuhn, MA; Peter Basch, MD; Michael Barr, MD, MBA; Thomas Yackel, MD, MPH, MS, for the Medical Informatics Committee of the American College of Physicians*
Ann Intern Med. Published online 13 January 2015 doi:10.7326/M14-2128

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Responses

  1. The links to “post comments” or “see all comments” give me a 404 error. David Gotlib MD

    • Sorry about that David. I cant quite see where those links are.. I wonder what part of the site you’re looking at?
      I note you’ve been able to leave a comment all the same.. could you explain a little more ? thanks, Tony


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