Report Suggests Ways To Improve Clinical Documentation in EHRs

January 15, 2015 in News

On Tuesday, the American College of Physicians released a report that details how to improve electronic health record clinical documentation and how to use technology to enhance patient care, EHR Intelligence reports (Reardon, EHR Intelligence, 1/13).

Details of Report

The authors compiled the report with input from ACP constituencies and non-member experts, as well as a literature review, according to Health Data Management.

In the report, the authors noted that “computers and EHRs can facilitate and even improve clinical documentation” (Slabodkin, Health Data Management, 1/13).

However, they also wrote that the use of technology could increase “inappropriate or even fraudulent documentation.” In addition, they wrote that “many physicians and other health care professionals have argued that the quality of the systems being used for clinical documentation is inadequate” (Walsh, Clinical Innovation Technology, 1/13).

Recommendations

To address such concerns, the authors outlined seven policy recommendations related to clinical documentation within EHRs:

  • Patient care support and improvement of clinical outcomes should be the primary focus of clinical documentation software;
  • Providers should define professional standards for clinical documentation practices within their organizations;
  • EHR systems should serve to improve care outcomes while contributing to data collection as value-based and accountable care models become more prevalent;
  • Structured data should be captured only where they are useful in care delivery or necessary for quality assessment and reporting;
  • Prior authorizations should no longer be unique in their data content and format requirements;
  • Giving patients access to their medical records, including progress notes, would improve patient engagement and care quality; and
  • Further research should be done to identify best practices for clinical documentation, develop automated tools, improve medical education related to EHR documentation and determine the most effective ways to disseminate professional standards for clinical documentation.

The authors also outlined five policy recommendations related to EHR design:

  • EHR developers should optimize systems for care delivery over time, as well as for care that involves teams of clinicians and patients;
  • Clinical documentation within EHR systems should be intuitive for clinicians;
  • EHRs should support a “write once, reuse many times” approach and use embedded tags to identify the original source of data;
  • EHR systems should not require clinicians to indicate whether an action has been taken if the data in the record already substantiate the action; and
  • EHR systems should enable the integration of patient-generated data (Kuhn et al., Annals of Internal Medicine, 1/13).

ACP’s governing board approved the recommendations (Health Data Management, 1/13).

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