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A recent publication, Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians takes a bold step in clarifying the persistent promise of an efficient patient record and quite possibly how recent transitions to the electronic health record (EHR) systems have left many feeling disappointed and even perhaps betrayed.
I for one applaud the opportunity for clinicians to be leaders in the drive to influence the evolving role of clinical documentation in alignment with the original goals cited below. The current iteration of EHR systems is defensive in nature and serves to block any litigious endeavor concerns resulting in a documentation process that obscures the basic tenets of improving patient outcomes.
The primary goal 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. Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.
Policy Recommendations for EHR System Design to Support 21st-Century Clinical Documentation
1. EHR developers need to optimize EHR systems to
facilitate longitudinal care delivery as well as care that
involves teams of clinicians and patients that are managed
2. Clinical documentation in EHR systems must support clinicians' cognitive processes during the documentation process.
3. EHRs must support “write once, reuse many times” and embed tags to identify the original source of information when used subsequent to its first creation.
4. Wherever possible, EHR systems should not require users to check a box or otherwise indicate that an observation has been made or an action has been taken if the data documented in the patient record already substantiate the action(s).
5. EHR systems must facilitate the integration of patient-generated data and must maintain the identity of the source.
Observe, record, tabulate, communicate.--Sir William Osler
Future blogs will address how this evolution can be managed both at the patient level and for the entire care pathway for a variety of therapeutic needs. You can send any questions or comments to firstname.lastname@example.org