Redesign EHRs to Fit Clinical Workflows, ACP Says

Ken Terry

January 12, 2015

A few months after the American Medical Association released a report blasting the poor usability of electronic health records (EHRs), the American College of Physicians (ACP) has followed with a position paper that calls for a fundamental redesign of EHR documentation so that it fits physician thought processes and workflows better.

The ACP paper, published in the recent issue of Annals of Internal Medicine, also asks the Centers for Medicare & Medicaid Services to consider revising its evaluation and management (E/M) coding guidelines. Although the specialty society of internal medicine does not specify how it wants these guidelines to be changed, its paper says that they distort documentation by forcing physicians to "backfill" their notes to meet the requirements. Thus documentation is "driven by the required number of [E/M] bullets to fulfill the requirements for a specific code," rather than by the clinical needs of the patient, the ACP says.

While the ACP opposes "whole note cloning," in which physicians copy patients' notes from one visit to the next, it encourages the copying of relevant findings from past notes into current notes to add context and increase the efficiency of documentation.

"We are concerned that, in reaction to clear abuses of copy/paste, regulators and health care institutions will attempt to put a blanket ban on all documentation methods where the documenter is not uniquely generating text in each document," the authors write.

The authors criticize current EHR documentation in several areas. First, they write, EHRs have made it too easy to generate voluminous documentation, often for defensive purposes. This leads to bloated notes that obscure important findings in reams of irrelevant and often impersonal details.

Second, there is too much emphasis on structured documentation, which is neither valuable nor necessary for much of patient care. "Structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting," the report states.

Third, the authors point out, the main goals of EHRs can't be achieved as long as the format and content of documentation is primarily based on coding and regulatory requirements. "An imbalance of values has been created, with compliance, coding and security trumping patient care, clinical well-being, and efficiency," they write.

The report also makes some recommendations for improvement. EHRs must facilitate longitudinal care delivery, support cognitive processes, support "write once, reuse many times," reduce the need to check boxes, and facilitate integration of patient-generated data. Most important, the authors write, "The needs of medical practice should drive the development of EHRs and not the reverse."

Serving Multiple Masters

Peter Basch, MD, chair of the ACP's Medical Informatics Committee and the lead author of the paper, told Medscape Medical News, "Clinicians who are unhappy or lost because of poor [EHR] usability, or who are focused on using EHRs for billing purposes" are unlikely to take better care of patients. "We want to make sure that the EHR as a tool for documentation requirements doesn't push in a direction that puts us at odds with patients."

Dr Basch doesn't think that copying relevant portions of a past note and inserting them into the current note increases the problem of note bloat, as long as the documentation in the previous notes is not overblown because of regulatory requirements. But he thinks that EHRs could be redesigned to provide a "timeline" showing how the previous visit's findings are related to current ones.

The ACP paper details that, because of the shift to value-based reimbursement, physicians are expected to use their EHRs to produce more and more quality data. But EHRs don't do a good job today of generating the requisite data as an outgrowth of clinical documentation.

Dr Basch said that EHR developers haven't focused very much on this area because they've been too busy rewriting their software for the meaningful use program. Among the possible ways to grab the quality data without burdening physicians, he said, is to use natural language processing technology that automatically places certain terms in the correct categories for quality reporting.

Julia Adler-Milstein, PhD, an assistant professor at the University of Michigan, who has written extensively about health information technology, also has high hopes for new technologies that will make EHRs more usable, including natural language processing. Alternatively, she told Medscape Medical News, "We could change the amount of required documentation, which would allow clinicians more time so that more thought can go into their notes."

Whatever happens, Dr Adler-Milstein said, documentation will continue to serve multiple masters, including reimbursement. "It will be interesting to see, as payment reform takes off, is…what will reduce the stranglehold around the documentation for billing and coding? We'll then need better documentation on the outcomes side."

Following phases in which EHRs were designed to maximize billing and to help physicians obtain government EHR incentives, she added, we're now entering a third stage in which EHR developers are increasingly focused on usability and interoperability. What's not clear yet, however, is whether market forces will create the conditions for a real breakthrough in the quality of EHRs, she noted.

Dr Basch and Dr Adler-Milstein have disclosed no relevant financial relationships.

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