Introduction
Observe, record, tabulate, communicate.
—Sir William Osler (1849–1919)
The medical record was first used by physicians to record their findings and actions and as a vehicle to communicate with other physicians who might care for the patient in the future. Physician notes were concise, were handwritten or dictated, varied in length and detail, and typically reflected the personality and style of the physician. They often contained nonstandard abbreviations and, if legible, were difficult to comprehend (
5). This was the documentation style of physicians until the early 20th century, when leading hospitals began to require structure and the use of forms to organize what had been essentially free-form notes in order to perform analyses of their medical records and improve quality. The use of forms and standardized data elements led physicians to note a “loss of the narrative descriptions” as well as the author's list of provisional diagnoses, speculations, opinions, and uncertainties. A sense that the notes had become dry recitations of facts led to a change in behavior by physicians, who began writing in the margins and on the backs of the tables because of frustration with the imposed formats (
5).
The concern about the loss of narrative continues today and is further complicated by an increasing demand for structured data for needs other than patient care, such as satisfying regulatory requirements and population health, and by the growing use of EHRs to view and create new documentation, which creates a new set of potential benefits, challenges, and unintended consequences.
Over time, clinical documentation has evolved in response to other pressures outside of the desire to improve systems of care in hospitals and care for individual patients. The medical record also became an essential legal document with requirements for nonmodification and retention, a vehicle for education of medical students and trainees, and the defined work product for which physicians were paid. Recently, the Meaningful Use program has expanded medical record documentation requirements to include specific information pertaining to payer quality measures and to serve as a vehicle for health information sharing with patients, families, and caregivers (
6). As patient engagement with the medical record continues, components of clinical documentation, such as the medical problem list, will shift from authorship by a single physician to authorship by multiple contributors and editors, including physicians, other nonphysician providers, and patients and families (
7).
In the past decade, medical records have become increasingly synonymous with EHRs. However, although “EHR” is the current term of art used to describe computer-based systems that perform a broad range of functions related to documenting and managing patient care, this will not always be the case. Similarly, clinical documentation's definition has grown to encompass more than just physician notes. Existing technology, such as registries, portals, connected home monitoring devices, and provider- and patient-controlled mobile devices, as well as technology not yet in use or even built, is likely to integrate with or possibly even replace the EHR (as currently conceptualized) as a primary vehicle for viewing and recording clinical documentation. Although the term “EHR” is used throughout this paper, the issues addressed could reasonably apply to any future technology-enabled system of clinical documentation.
This position paper reviews the current and emerging purposes of clinical documentation, the drivers that may influence or distract from these purposes, and the opportunities and challenges that have arisen from EHRs. We believe that physicians must help define and prioritize the many important roles that clinical documentation serves today. Therefore, this paper proposes a set of guiding principles and actions that can be taken by clinicians, provider institutions, technology vendors, government regulators, payers, and other interested groups to improve the quality and value of clinical documentation and to better use this documentation to improve care.
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 Clinical Documentation
Clinical documentation, whether on paper or in an EHR and regardless of other drivers, should strive to effectively and efficiently serve the purposes of documentation as described by Sir William Osler: “record, tabulate, communicate.” Although there are perceived and real issues with the functionality and usability of EHRs, they have the potential to improve the viewing, analysis, and communication of clinical information, and as they become more interoperable, it is critically important that what they record is accurate.
The College makes the following recommendations for clinical documentation. Most clinical documentation is now or will soon be completed in EHRs, and our recommendations are therefore made in this context. The College strongly supports the use of EHRs in clinical medicine on the basis of the potential to improve quality of care provided to individuals and populations.
The College strongly supports the use of new capabilities within EHRs and other health information technology to enhance the efficiency and accuracy of documentation as well as the transformation of the medical record from predominantly a reflector of gathered information to a dynamic, team-oriented communication tool that serves the entire care team, including patients and families. To these ends, the College offers the following policy recommendations.
1. The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.
The primary purpose of clinical documentation is to facilitate excellent care for patients. Whenever possible, documentation for other purposes should be generated as a byproduct of care delivery rather than requiring additional data entry unrelated to care delivery. The consequences of having additional primary purposes for clinical documentation, such as defensive documentation, drive excessive documentation and need to be addressed (
19). Also, the current E&M guidelines cause many unintended negative consequences of clinical documentation. To the extent that the E&M system is maintained as is, creative solutions to improve and simplify clinical documentation will be difficult to introduce because current documentation is driven by the need to support billing and comply with regulatory and coding requirements. Furthermore, the College believes that the recommendation by the Office of Inspector General of more education to address its recent finding that almost half of all E&M visits for Medicare patients are coded incorrectly is not only the wrong approach to the problem but fails to acknowledge what should be self-evident. Regulations should be clear and should address clinical workflow without adding burden for documentation solely for the purpose of obtaining reimbursement. It is a waste of time, money, and focus to continue to force what can be viewed metaphorically as the round pegs of clinical practice into the square holes of the E&M documentation guidelines. Ultimately, billing requirements should be adjusted to accept accurate documentation generated for clinical purposes.
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.
Good documentation is a fundamental component of high-quality care. Professional standards for high-quality computer-based clinical documentation should keep the best elements of paper-based documentation without duplicating its inefficiencies and limitations. The standards should emphasize clarity, brevity, and attention to the needs of other readers, including patients. Consensus-driven standards could form the basis for modifications to the E&M guidelines.
No one format is appropriate for all specialties or clinical situations, but each organization or practice should develop “chart etiquette” principles and policies based on a well-defined set of standards. These professional standards should address the following key issues:
A. The clinical record should include the patient's story in as much detail as is required to retell the story.
When permitted by regulations, it may contain entries by the patient as well as other care team members.
B. When used appropriately, macros and templates may be valuable in improving the completeness and efficiency of documentation, particularly where that documentation is primarily limited to standardized terminology, such as the review of systems and physical examination findings.
C. The EHR should facilitate thoughtful review of previously documented clinical information. Ready review of prior relevant information, such as longitudinal history and care plans as well as prior physical examination findings, may be valuable in improving the completeness of documentation as well as establishing context.
When data are pulled from another location in the chart, the source of the data should be indicated, and the data should be supplemented by appropriately abstracted narrative content and, when appropriate, should be referenced and traceable.
D. Where previously documented clinical information is still accurate and adds to the value of current documentation, this process of “review/edit and/or attest, and then copy/forward” (hereafter referred to as copy/forward) of specific prior history or findings may improve the accuracy, completeness, and efficiency of documentation. However, these documentation techniques can also be misused, to the detriment of accuracy, high-quality care, and patient safety.
Electronic health records offer an easier way to see relevant prior history, information, and findings in rich historical context than paper records. When such capabilities are present, the College encourages their use because they allow for better and more focused interim history taking and a ready comparison between what was previously observed and what is currently observed. In fact, it is reasonable to assume that this approach, when done thoughtfully, can result in more accurate documentation in certain settings, particularly for ongoing preventive and chronic care. Regardless of the method used, clinical documentation tends to be repetitive, with the same words or phrases used to describe common observations each time they are made.
There is great concern throughout the medical community about a variant of copy/forward known as “copy/paste,” where an entire note is copied into the same or another patient's records, with the clinician intending to edit the new note such that it accurately represents the new history, examination, assessment, and plan (
26). When most of the copied note is accurate for the same patient in another encounter or for a different patient, and little or no editing is needed, copy/paste can save time and keystrokes. However, this is often not the case. There are too many examples of copying without editing that results in computer-generated notes with factual errors that are passed from note to note and old dates and values, such as vital signs and intake and output, that are not updated. As opposed to the documentation techniques mentioned earlier (macros, templates, and selective copy/forward), which add benefit with less risk, the copying and pasting of an entire note is inherently risky and should be avoided. 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. Use of any documentation tool by itself should not be considered evidence of improper documentation practice. More study is needed to separate valuable uses of documentation tools from abuses of them. That said, if clinicians carry forward previously generated templates, default verbiage, or information (via copy/forward or macro-generated text), they must exercise caution such that what is documented is accurate and reflects the history, findings, and decision making for that visit. Furthermore, when leveraging templates, default verbiage, or previously documented information, the documenter should not create contradictory information or excessive documentation (beyond what is necessary for defensive medicine, regulatory purposes, quality measurement, and compliance with an appropriate E&M code).
The College further recommends that CMS, other payers, and other organizations that have issued blanket guidance against note cloning reexamine their existing guidance, which equates and confuses the method with the end result.
E. Effective and ongoing EHR documentation training of clinical personnel should be an ongoing process.
Recent evidence shows that the quality and quantity of training and support can significantly affect the ability of staff to make optimal use of the system. Additional training is required with every system upgrade. Inappropriate data entry practices can be reduced by thorough training combined with well-thought-out institutional policies that balance local compliance requirements with support for efficient documentation.
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.
The data needs of large, complex entities could result in additional data collection requirements for physicians and their clinical teams that detract from the core workflow processes associated with direct patient care. To the extent possible, metrics designed to support analyses of quality and value should leverage data collected in the usual course of patient care, with appropriate attention to privacy and other ethical concerns, rather than requiring clinicians to take extra time to collect structured data not essential to patient care. When data are required beyond those that are generated as a consequence of care delivery, clinicians, practices, and health care systems should be compensated for time spent collecting these additional data.
4. Structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting.
To preserve the integrity of the patient narrative, requirements for capture of structured data should be kept to a minimum. Structured data should never take the place of narrative comments when such data change the meaning of the patient's narrative. Physicians should not be required to code data elements for third parties that are not essential for the provision of safe, high-quality, and high-value care. Coding and structured data entry by physicians or staff should only be considered in cases where the value of the coded element is extremely high and the data element cannot be readily abstracted from the note with sufficient accuracy by using natural language processing, which involves computer-based abstraction and coding of terms from narrative text (
19).
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.
Reasonable information required for most prior authorizations for testing and treatment purposes should be part of most clinical documentation. When that information exists, payers and others who have prior authorization requirements should modify their requirements to use the relevant data collected during the provision of care rather than requiring redundant data collection solely for the purpose of completing prior authorization forms. Payers should collaborate with medical societies and other interested stakeholders to define what data points are most important for prior authorization 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.
Studies of open notes have shown improved engagement of patients in their care, and patient review provides a new form of peer review to improve accuracy in documentation (
27). However, it is too early to push for broad implementation. Although the study and use of open notes should be expanded, providers should have the option of “opting out” individual notes from automatic release in the small percentage of cases where such release could be harmful to the patient.
7. The College calls for further research to:
A. Identify best practices for systems and clinicians to improve accuracy of information recorded and the value of information presented to other users.
B. Study the authoring process and encourage the development of automated tools that enhance documentation quality without facilitating improper behaviors.
C. Understand the best way to improve medical education to prepare new and practicing clinicians for the growing uses of health information technology in the care of patients and populations and to recognize the importance of their responsibility to document their observations completely, concisely, accurately, and in a way that support their reuse.
D. Determine the most effective methods of disseminating professional standards of clinical documentation and best practices.
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 over time.
The primary purpose of a health record is to support care delivery over time and across all venues in which patients receive care, including such new processes as shared decision making, care coordination, and the delivery of high-value care. Vendors need to improve the ability of systems to capture and manage structured data as well as thought processes, descriptions, speculations, opinions, and uncertainties. Important elements of documentation, such as the patient narrative and differential diagnosis, cannot be lost as a consequence of overstructuring or underdesigning the user interface (
28). The needs of medical practice should drive the development of EHRs and not the reverse (
29).
2. Clinical documentation in EHR systems must support clinicians' cognitive processes during the documentation process.
Clinicians must be able to view related information without having to navigate away from a window in which they are working (
30). Each data element needs to be examined and assessed for a more automated and accurate way to capture that element. More easily generated hybrid notes that include narrative as well as some template-driven components (such as duration, ameliorating or exacerbating factors, or pattern) might be a significant improvement over many available documentation options. Electronic health record systems must enable collection of data and interpretation of information from multiple sources by clinicians as appropriate and necessary, including nuanced medical discourse, structured items, and data captured in other systems and devices (
30).
In addition to cognitive support, EHR vendors need to make sure that the technology options include reasonable accommodations for expected partial disabilities, such as various arthritic conditions, the carpal tunnel syndrome, vision and hearing loss, and cervical spine disease.
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.
Electronic health record systems must allow clinicians to easily search available data during note writing and must give the option of linking content from prior entries or copy/paste with appropriate tags. To the extent that the reusability of the collected data is increased, the need to collect additional data for secondary purposes will be decreased. This will benefit everyone involved (
31).
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).
Some systems require documentation of the same content multiple times. For example, even though a member of the clinical team records measures of height, weight, and blood pressure during patient intake, some EHR systems require physicians to check a separate box to show that they screened for high blood pressure and obesity. Because of the complex and variable nature of many clinical activities, there will always be some need to document a set of actions and then acknowledge that they were documented, but these should be minimized to the extent possible. The EHR should auto-attest to the clinician's use of the record. If the physician reviewed the laboratory result, the EHR should record and attest to this behind the scenes in a way that satisfies compliance, audit, and billing requirements rather than requiring the physician to redundantly pull information from one part of the record into the visit note for billing justification or to redundantly report all of the screening tests within the record that were reviewed.
5. EHR systems must facilitate the integration of patient-generated data and must maintain the identity of the source.
This will require that the provenance of all data in the clinical record is recorded and managed along with the data (
18). Physicians and other health care professionals must be able to trust the data, which means that they must be able to understand the source of and the route taken by all data. Electronic health record systems should support joint patient–provider decision making, team collaboration, care process management, and advanced CDS (
19).
How E&M Coding Destroyed Communications between Physicians
The latest debacle is the CCD: a clinical care document, created by EMR systems for physicians meeting the requirements of meaningful use. The CCD is nothing but a compilation of all the useless data elements with no communication of useful information such as a physician's opinion or the patient's story. As a primary care internist, I am forced to look through these useless CCDs in the hope of finding a shred of communication about the patient.
I don't know what the solution is, but this paper is pointing in the right direction. The 1997 E&M coding guideline needs to be re-engineered and the CCD needs to be retooled to make it more clinician friendly.
Congress gave health insurers the right to violate patient privacy - this must end
There is a natural tension between physicians, who want to be paid in full for their efforts, and payers, who want to minimize payments to physicians. Payers enforce physician adherence to E&M documentation and billing regulations by hiring clerical employees called “coders” to audit patients’ clinical charts for documentation deficiencies. To avoid fines and prosecution, physician notes are usually generated first and foremost to fulfill the requirements of these coder audits, rather than the needs of their fellow clinicians.
Coders determine whether a progress note meets the billing requirements mainly by checking how many elements of defined data are present. Most physicians are not completely familiar with the complex, confusing, and arcane E&M requirements, so they load up their notes with as much computer-generated boilerplate as they can, hoping it will include an overlooked element of data needed to satisfy a coder’s audit.
This whole system must be discarded, or there can never be any hope of having progress notes that communicate clearly and concisely between clinicians. A quick and sure way to end this “tyranny of the coders” is for Congress to terminate the exemption granted to payers by the patient privacy laws, including HIPAA. This would eliminate inspection of the clinical chart by payers and their coders. Payers would no longer need battalions of coders, who could be relieved of their duties and retrained to perform more productive tasks.
Payers should not be allowed to read, inspect, or audit patients’ clinical charts; this is a violation of patients’ medical privacy. It harms patients by causing physicians to spend more of their limited time generating progress notes, leaving less time for interacting with patients. Payers must verify physician billings in some way which does not violate the privacy of patient charts. Payments could be determined by the average amount of physician time required to treat the patient’s illnesses and manage their chronic conditions, as determined from the submitted diagnosis codes. Physicians could submit attestations for any required variations. In a world without E&M coding requirements, the clarity and efficiency of clinical documentation could be improved enormously, with more time for physicians to actually examine and treat patients.
Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the ACP
These requirements include meaningful use (most providers have failed the onerous requirements for EHR infrastructure incentive payments under the second round), the Center for Medicare and Medicaid Services outpatient Physician Quality Reporting System Measure-Applicability Validation Process (my infectious diseases practice is currently appealing ~1% reimbursement cuts for physicians who don’t even see outpatients), documentation and coding requirements for inpatients (which not only affects hospital reimbursement, but also acceptable lengths of stay and mortality rates for hospital monitoring purposes), and hospital reimbursement penalties under Value Based Purchasing (VBP), Hospital Acquired Conditions (HAC) and the Hospital Readmissions Reduction Program (HRRP).
One solution to the regulatory problem may be through electronic data extraction methodologies that go beyond the myriad of check off boxes and “copy and pastes” within the record. Our health system is about to implement one of these electronic systems. There are many examples of how the system will function. It can cull the electronic record daily to identify patients who no longer have indications for a Foley Catheter and thus decrease Catheter Associated Urinary Tract Infections under both the VBP and HAC programs. The system will cull radiologic studies and electronic physician notes for “pleural effusion” in cases of iatrogenic pneumothorax. Diagnosis code 5119 (pleural effusion NOS) excludes Patient Safety Indicators (PSI 06) related penalties for iatrogenic pneumothorax under both the VBP and HAC programs. A template will be used to assist the system to cull data to identify congestive heart failure patients appropriate for hospice care. The latter will not only assist in patient care but will also diminish 30 Day Mortality Rate penalties within VBP. The electronic data extraction system will also be used to optimize documentation and coding as our institution switches from ICD-9 to ICD-10. However, the real goal of these methodologies will be to allow the physician to concentrate on the true purpose of the EHR, to richly tell the story, enhance critical thinking and assure communication among providers, patients and families.