ACP: Clinical documentation in EHRs should be revamped, more 'concise'

Electronic health records can be used to prioritize and improve clinical documentation, according to a new policy position paper from the American College of Physicians (ACP) published in the Annals of Internal Medicine.

EHRs have made "defensive documentation" easier, leading to "note bloat," according to the authors, writing for ACP's Medical Informatics Committee. Problem oriented medical record keeping, the use of evaluation and management guidelines and requirements for structured data also increase documentation burdens, they say.

However, the primary goals 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," the authors say.  

With that in mind, the ACP recommends seven guidelines for EHR documentation:

  1. The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
  2. Physicians working with their care delivery organizations, medical societies, and others should define professional standards regarding clinical documentation practices throughout their organizations. Further, clinical usefulness of health information exchange will be facilitated by appropriate redesign of clinical documentation based on consensus-driven professional standards unique to individual specialties as a result of collaboration with standards-setting organizations.
  3. 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.
  4. Structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting.
  5. Prior authorizations, as well as all other documents required by other entities, must no longer be unique in their data content and format requirements.
  6. 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.
  7. The College calls for further research to identify best practices, determine the best way to improve medical education, and other areas.

The ACP also suggests changes in EHR design to support these changes, such as using embedded tags to identify the original source of information and facilitating the integration of patient generated data.

In an accompanying editorial, Thomas Sequist, M.D., from Partners Health Care System, Brigham and Woman's Hospital and Harvard Medical School, notes that documentation should be more "high value" and  that "[t]he true power of EHRs may be in moving from documenting isolated clinical transactions to describing whole-patient care from multiple stakeholder viewpoints."

Studies have shown that EHRs increase physicians' administrative burdens since documentation takes longer when using an EHR. One recent study found that physicians lost hours of time each week to EHR technology.

To learn more:
- read the paper
- here's a preview of the editorial