September 12, 2018
Regaining the value of EHR documentation
By: Dr. Ron Moody

Medical record documentation should be about communication, and helping to support longitudinal care. The unstructured narrative of medical records had great value, improved by adding a simple formatting structure to how content was captured using such items as SOAP and History and Physical formats. This helped expedite the review and discovery of information.

Healthcare teams used to actually look through the narrative for a better understanding of the patients, their lives and plan. Time was spent conveying patient-centric information and the thought process behind care. This gave a more personalized, less boilerplate record of the patient’s health journey.

Electronic health records (EHRs) were supposed to help improve the value of the medical record beyond improving legibility. So far, that has not been the case. EHRs have been very good at getting medical professionals to check boxes and to auto-populate boilerplate text. They are also creating a cottage industry of additional staff to click boxes for the physician and people to monitor clicks.

I don’t believe this is what anyone had in mind for electronic records as a channel to advance the patient narrative and move toward the Triple AIM.

EHRs have helped with data accessibility. No more searching for the result slip or often the chart itself. A handwritten narrative typically made sense and often included information on the writer’s thought process. Reading your own note during a subsequent encounter quickly brought you back, not just to your thinking but to the very personal understanding of the patient and his or her condition, often from the patient’s voice.

While that note was being written, interruptions from alerts, reminders, notifications or clarifications about billing were less common. The physician did not struggle with finding the right box to click to find the exact—or closest—description of the patient, the patient’s condition, or the specific physical finding. The narrative was understandable and nuanced. Today, many of us are suffering from Alert/Notification fatigue and boilerplate notes that are bloated.

I’m not suggesting healthcare should move back to paper documentation. Nor do I think that my notes were ever great works of English literature. It is clear that paper records were flawed, and many of those flaws have been codified in EHRs. Achieving the Triple AIM, accountable care, value-based care and patient-centric care involve asking how we can change care delivery models to achieve the best outcomes, with technology being the enabler.

Let’s solve interoperability where it matters—medication and allergies would be an ideal place to start. Let’s start fixing problems based upon improved outcomes, instead of simply implementing band-aid fixes. Healthcare delivery and the supporting technology should change to support today’s needs and an evolving future. Change can and should occur now but should be value-driven.

For example, the current practice of hiring scribes to write notes that doctors likely will never read may need to be reconsidered. If the issue is inefficient note creation that often has little value, won’t be read again and is going to create data that persist longitudinally, that problem should be addressed.

It is tempting for doctors to blame those terrible EHR companies for the state of communication in and outcomes from EHR implementation. We need to take ownership of it ourselves, to view technology as the enabler and not as the driver. The focus needs to be simplifying the process of collecting and communicating a patient’s personal history, to streamline the system and improve outcomes. It can’t be about boxes, and digital clicks, and limiting the ability to achieve better results.

In my next blog, we’ll explore actions to change how the EHR impacts documentation, collaboration, and health delivery now while we all push to improve the tools necessary for patient-centric, value-driven healthcare, which requires more than an EHR:

  • Medical record documentation must support healthcare and collaboration.
  • The fix to bad processes and technical implementation is not more staff.

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