Clinical Documentation: When Is There Too Much Information?
As federal regulations and requirements are more often on the minds and mouths of administrators, so too is the concept of accountable care. A large part of this initiative is the concept of clinical documentation, designed to make sure necessary procedures and safety requirements have been undertaken to assist in quality of care and billing/payment initiatives. However, a clinical documentation initiative is not without its pain points, but there are ways to troubleshoot documentation woes.
In terms of payment and billing documentation, Peter Basch, MD, medical director of ambulatory EHR and health IT policy at MedStar Health in Columbia, Md., says that documentation is denser than it should be. "We see a lot of complaints from colleagues that the output of the EHR note is cluttered with extraneous information that is not helpful to understanding the content," laments Basch. "EHR users for the most part are not the cause."
A step forward could be to modify the Centers for Medicare & Medicaid Services' (CMS) evaluation and management documentation guidelines, recommends Basch, who adds that this could "change how we pay for care. Once we move away from our fear of compliance, then we can use EHRs to create relevant documentation useful to providers, specialists and patients."
There are workarounds, however, that allow providers to comply with guidelines while still reducing documentation clutter, Basch says. For instance, during visits that do not require patients' complete medical history and physical, there is no need based on clinical or coding necessity to restate every clinical list for the patients, such as their family history or past procedure's list. "There is only a clinical need to look at the documentation to see if there's anything in those lists pertaining to their current condition," he says.
MedStar—a 3,300-bed nonprofit provider that receives about 162,000 inpatient admissions and 1.49 million outpatient visits annually, and serves the greater Washington, D.C./Baltimore area— built features into its EMR to alleviate clinical documentation debris. "We've enabled the EMR to readily show information to patients and physicians that allow them to quickly scan the lists and document that they've reviewed the information for relevance to the patient visit," Basch says. Medstar, while simultaneously attempting to pay attention to a coding requirement, is focused on reducing the multiple pages generated instead of focusing on shorter notes to get more at the signal than the associated noise.
Allowing clinical information to be documented, shared and accessed by hospitals is one way of achieving and giving high quality care to patients, Schiff notes. "I recently stumbled across a [normal] scan taken just a month earlier from another hospital and little had changed in the interim [for the patient], making it safe to not treat with anticoagulants without repeating the scan," he says.
In addition to interoperability, Schiff suggests better search capabilities currently are needed within the EMR. "Retrieving clinical information in real time is needed. However, information overload will overwhelm clinicians and clinical workflow, and too much information to review will replace missing information as the dominant problem for clinicians," he says.
Clinical documentation shouldn't be thought of as a "gloom and doom" topic. On the contrary, there are currently facilities seeing positive returns on collaborative clinical documentation. The Cleveland Clinic, which includes nine regional hospitals and 16 family health centers, and whose clinicians see 3.8 million patient visits per year, has seen dramatic improvement in the quality of its documentation, as well as real-time decision support by integrating a clinical documentation system within its EMR, according to William Morris, MD, interim CMIO.
"Traditionally, clinical documentation is the plan of care for the patient; the clinical thought process," Morris says. "It also is the vehicle for billing, coding, as well as research and quality abstraction. Thus, documentation has become the arbiter of outcomes of the clinical care experience."
While overhauling its clinical documentation process about two years ago, the Cleveland Clinic found the documentation didn't reflect the complexity of the patient's condition. "If we're going to be measured against our peers on patient outcomes, the capturing of the clinical care has to be flawless," says Morris.
Recognizing the need for a longitudinal, discreet diagnosis-centric data capture, the Cleveland Clinic's Heart and Vascular Institute implemented problem-oriented charting. These real-time discrete diagnoses are integrated into daily documentation and feed into clinical decision support and algorithms that help with risk adjustments and drive better patient care. According to Morris, this single-source-of-truth approach, as opposed to a traditional free-form daily progress note, has brought a level of transparency and clarity about the patient.
"If multiple services are looking and managing a problem list in the inpatient setting, the problem list can be edited and updated to reflect the patient's current status. This approach drives a collaborative decision-making approach among providers," Morris applauds. "The problem list evolves and the accuracy of the record improves over time."
The system is a big hit with nursing staff, as well, because they can assess a plan of care that evolves as providers engage with the patient's chart. "From a quality standpoint, we conduct real-time queries of the database so we can engage providers as close as possible to where it's post-ad hoc analysis," Morris says.
Since a silver bullet has not been developed for clinical documentation processes, it's important that executives assess their documentation needs and systems before jumping into the technology adoption effort.
Types of documentation
While seen as part of the building blocks to restructuring an industry that has been lagging behind in the adoption of IT to promote efficiency, some believe that documentation guidelines are clouding the potential of the clinician's workflow.In terms of payment and billing documentation, Peter Basch, MD, medical director of ambulatory EHR and health IT policy at MedStar Health in Columbia, Md., says that documentation is denser than it should be. "We see a lot of complaints from colleagues that the output of the EHR note is cluttered with extraneous information that is not helpful to understanding the content," laments Basch. "EHR users for the most part are not the cause."
A step forward could be to modify the Centers for Medicare & Medicaid Services' (CMS) evaluation and management documentation guidelines, recommends Basch, who adds that this could "change how we pay for care. Once we move away from our fear of compliance, then we can use EHRs to create relevant documentation useful to providers, specialists and patients."
There are workarounds, however, that allow providers to comply with guidelines while still reducing documentation clutter, Basch says. For instance, during visits that do not require patients' complete medical history and physical, there is no need based on clinical or coding necessity to restate every clinical list for the patients, such as their family history or past procedure's list. "There is only a clinical need to look at the documentation to see if there's anything in those lists pertaining to their current condition," he says.
MedStar—a 3,300-bed nonprofit provider that receives about 162,000 inpatient admissions and 1.49 million outpatient visits annually, and serves the greater Washington, D.C./Baltimore area— built features into its EMR to alleviate clinical documentation debris. "We've enabled the EMR to readily show information to patients and physicians that allow them to quickly scan the lists and document that they've reviewed the information for relevance to the patient visit," Basch says. Medstar, while simultaneously attempting to pay attention to a coding requirement, is focused on reducing the multiple pages generated instead of focusing on shorter notes to get more at the signal than the associated noise.
The need for speed
Clinicians, like Gordon D. Schiff, MD, associate professor of medicine at Harvard Medical School, believe there is great potential for the proverbial computer to perform clinical documentation with accuracy yet to be seen. However, the potential for this enhanced clinical documentation still has to be realized, he says.Allowing clinical information to be documented, shared and accessed by hospitals is one way of achieving and giving high quality care to patients, Schiff notes. "I recently stumbled across a [normal] scan taken just a month earlier from another hospital and little had changed in the interim [for the patient], making it safe to not treat with anticoagulants without repeating the scan," he says.
In addition to interoperability, Schiff suggests better search capabilities currently are needed within the EMR. "Retrieving clinical information in real time is needed. However, information overload will overwhelm clinicians and clinical workflow, and too much information to review will replace missing information as the dominant problem for clinicians," he says.
Clinical documentation shouldn't be thought of as a "gloom and doom" topic. On the contrary, there are currently facilities seeing positive returns on collaborative clinical documentation. The Cleveland Clinic, which includes nine regional hospitals and 16 family health centers, and whose clinicians see 3.8 million patient visits per year, has seen dramatic improvement in the quality of its documentation, as well as real-time decision support by integrating a clinical documentation system within its EMR, according to William Morris, MD, interim CMIO.
"Traditionally, clinical documentation is the plan of care for the patient; the clinical thought process," Morris says. "It also is the vehicle for billing, coding, as well as research and quality abstraction. Thus, documentation has become the arbiter of outcomes of the clinical care experience."
While overhauling its clinical documentation process about two years ago, the Cleveland Clinic found the documentation didn't reflect the complexity of the patient's condition. "If we're going to be measured against our peers on patient outcomes, the capturing of the clinical care has to be flawless," says Morris.
Recognizing the need for a longitudinal, discreet diagnosis-centric data capture, the Cleveland Clinic's Heart and Vascular Institute implemented problem-oriented charting. These real-time discrete diagnoses are integrated into daily documentation and feed into clinical decision support and algorithms that help with risk adjustments and drive better patient care. According to Morris, this single-source-of-truth approach, as opposed to a traditional free-form daily progress note, has brought a level of transparency and clarity about the patient.
"If multiple services are looking and managing a problem list in the inpatient setting, the problem list can be edited and updated to reflect the patient's current status. This approach drives a collaborative decision-making approach among providers," Morris applauds. "The problem list evolves and the accuracy of the record improves over time."
The system is a big hit with nursing staff, as well, because they can assess a plan of care that evolves as providers engage with the patient's chart. "From a quality standpoint, we conduct real-time queries of the database so we can engage providers as close as possible to where it's post-ad hoc analysis," Morris says.
Since a silver bullet has not been developed for clinical documentation processes, it's important that executives assess their documentation needs and systems before jumping into the technology adoption effort.
| Clinical Documentation— Oh, the Possibilities |
| Gordon D. Schiff, MD, associate professor of medicine at Harvard Medical School, and David W. Bates, from the division of general internal medicine at Brigham and Women's Hospital in Boston, wrote in a March 2010 article in the New England Journal of Medicine that electronic clinical documentation may help prevent diagnostic errors.The article contained examples of the goals and features of redesigned systems via electronic documentation. The authors' goals were:
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