FROM ANNALS OF INTERNAL MEDICINE
Electronic health records need to focus less on lists of check boxes and reimbursement and more on narrative entries and designs that improve patient care, according to a new policy statement from the American College of Physicians.
Documenting clinical information via drop-down lists, check boxes, macros, and templates can be distracting and disruptive to vital clinical thinking and storytelling, wrote Thomson Kuhn of the ACP and his colleagues. The policy recommendations were published Jan. 13 in Annals of Internal Medicine.
The authors warned against “overstructuring the clinical record and overloading it with extraneous data” and further devaluing the importance of narrative entries (Ann. Intern. Med. 2015 Jan. 13 doi:10.7326/M14-2128 ).
Complex and contradictory drivers are influencing the development of EHRs, so now seems a good time to reconsider what and how information is being documented, Dr. Peter Basch , medical director of ambulatory EHR and health IT policy at MedStar Health of Washington, D.C., and chair of the ACP Medical Informatics Committee, said in an interview.
On the one hand, the Office of the National Coordinator for Health Information Technology “calls for leveraging health IT to improve the consistency of documentation. At the same time and previous to that, the [HHS Office of Inspector General] has implied that seeing the same or very similar phrases in clinical documentation, whether in the same patient over a period of time or in different patients, could be evidence of note-cloning, and thus billing fraud,” said Dr. Basch, a coauthor of the policy statement.
The focus on reimbursement in the design of EHRs limits market creativity and makes it difficult to introduce solutions that simplify the clinical documentation process, he added.
“Regulations should be clear and should address clinical workflow without adding burden for documentation solely for the purpose of obtaining reimbursement,” the ACP policy statement notes.
The ACP is calling on health care delivery organizations, medical societies, and others to define standards for clinical documentation, something that will allow the sharing of data. “No one format is appropriate for all specialties or clinical situations, but each organization or practice should develop ‘chart etiquette’ principles and policies based on a well-defined set of standards.”
And one area where ACP would like to see standardization specifically highlighted is in common forms such as prior authorizations so that they would “no longer be unique in their data content format requirements.”
ACP also called for research in a number of areas, including identifying best practices, developing automation tools that enhance document quality without facilitating improper behavior, improving medical education around health information technology, and finding effective ways to disseminate professional standards of clinical documentation and best practices.
