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October 01, 2018
Refining the approach to EHR documentation for better outcomes
By: Dr. Ron Moody

Many EHRs evolved from billing/practice management systems. They remain focused more on the business of healthcare than outcomes—other than financial—or efficiency (outcomes/cost).

EHRs brought improvement to coding and billing processes, which many clinicians were happy about. But they also created task-shifting, documentation, and compliance tracking processes that clinicians despised. Business efficiency is important, but it’s not the primary goal in adapting electronic record-keeping. Health improvement and healthcare efficiency should be the priority. This has not always been the case.

It is evident in how coding and billing is deployed consistently across EHRs. This architecture helped create many of the issues that physicians rail against today. The need to meet healthcare compliance rules added more clicks to the process, so that actions—or at least clicks—could be monitored.

This data collection approach has invaded the structure of the narrative, further reducing its value. In EHRs, progress notes now include compliance as part of either the chief complaint or subjective, although neither really belongs there.

We’ve lost sight of what EHRs should accomplish in that regard, and how we should view them. They are a means to a better end, not the end itself. As clinicians, we also control how we use the tools provided.

To create simplified documentation and more effective communication, let’s start with some actions we control:

  • Don’t add historic content from previous notes or collected data unless there is a specific clinical need. This will help limit note bloat. The note should support delivery of longitudinal care and collaboration as the legal medical documentation, while secondarily supporting administrative and billing. Too much content can create as much risk as value.

  • Capture structured data where established, evidence-based processes for use and value-added decision supports exist, such as CPOE, or where the provider has a specific need to track—Ocular Pressure or Ejection Fraction. An intelligent patient record can ask for these details based upon diagnosis or other available data. This will drive the EHR user to add more data based upon value from analytics and decisions support.

  • Push for a consolidated view of all patient data regardless of source while showing provenance. Start with a 360-degree of healthcare data, growing to include patient-provided and generated health and life data. This data should be directly editable and longitudinally usable for collaboration.

We need to step back from rigid, idealized workflows and endless check lists, while moving forward to create solutions to identified problems. Process change can provide solutions; technology change isn’t necessary. Solutions may include tech and process as supporting narrative text entry for communication and readability, while adding Natural Language Processing and Artificial Intelligence to harvest data from new (and old) notes after the encounter.

Regardless of the EHR system, solutions can be implemented to remove stress points today while providing the opportunity to evolve and expand through new technology and work processes. Our focus must be based on adding value, not additional work or cost. Making this transition should involve free text use to support clinical care, communication, and workflow; use of templates to capture essential data, and changing the process to focus on the outcome, not the EHR.

We shouldn’t lose sight of perhaps the two most important aspects:

  • Clinicians can change the way we use tools today to improve EHR usability.

  • Process as well as technology change is critical to achieving outcomes.

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