NEJM: Physicians must 'take back' ownership of EHRs
Clinical documentation plays a central role in EHRs and occupies a substantial amount of physicians’ time, but documentation practices have largely been dictated by billing and legal requirements, according to a New England Journal of Medicine online article published by Gordon D. Schiff, MD, and David W. Bates, MD, on March 25. The authors urged physicians to “take back” ownership of the medical record as a tool for improving patient care.
EHRs must be designed to enhance clinicians’ workflow and quality of care, according to Schiff and Bates: “We envision a redesigned documentation function that anticipates new approaches to improving diagnosis, not one that relies on the putative “master diagnosticians" of past eras.”
Systems developers and clinicians need to reconceptualize documentation workflow as part of the next generation of EHRs, and policymakers must lead by adopting a more rational approach than the current one, “in which billing codes dictate evaluation and management and providers are forced to focus on ticking boxes rather than on thoughtfully documenting their clinical thinking,” according to the authors.
Because information from patients’ previous clinical encounters and tests will be more readily available with EHRs, they could substantially improve clinicians’ knowledge about the patient.
“The problem of having too much information is now surpassing that of having too little, and it will become increasingly difficult to review all the patient information that is electronically available. However, one virtue of computerized systems is that they can display recorded information in various formats. Designers will need to leverage the ‘visual affordance’ capabilities of EHRs to facilitate aggregation, trending and selective emphasis or display of data so as to facilitate rapid judgments,” the authors wrote.
EHRs can also foster assessment by serving as a place where clinicians—and patients—document evaluations, “craft thoughtful differential diagnoses, and note unanswered questions.” Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient’s history and making assessments, and notes should be designed to include discussion of uncertainties.
Documentation of clinicians’ thinking must be facilitated by streamlined text-entry tools such as voice recognition. “Exam-room layouts, screen placement and workflow should be redesigned to enable patients and physicians to work together on the same side of the screen. Follow-up questions should be documented in ways that facilitate tracking and sharing with future providers and consultants.”
EHR systems should document evolving history and ongoing assessment, and electronic notes should follow an evolutionary paradigm—especially for chronic conditions, according to Schiff and Bates. “Putting this strategy into effect will require us to go beyond reflex criticism of copy-and-paste methods to a search for creative approaches based on functions such as annotation, tracking of changes, and threads that not only enable information to be carried forward but also allow it to be continuously refined and updated."
A better approach to managing problem lists is also needed. "The failure to effectively integrate problem lists into the clinician’s workflow has been one of the great failures of clinical informatics,” the authors wrote. Most EHRs today lack tools for easily reordering these lists and allowing specific providers to work selectively with a subset of problems, they said.
EHRs should ensure fail-safe communication and action when ordering tests and tracking results. “Better tools are needed to efficiently weave results management into EHR documentation and workflow and to link laboratory results to problem lists and medications,” the authors wrote.
Electronic systems should incorporate checklist prompts to ensure key questions are asked and relevant diagnoses are considered. Diagnostic checklists have so far been neither clinically helpful nor widely used, Schiff and Bates claimed, “yet human memory alone cannot guarantee that key questions will be asked and important diagnoses considered and accurately weighed.” Practical, evidence-based decision-support software and predictive models that automatically generate differential diagnoses, facilitating both documentation and decision making, would be a great help, they said.
Electronic systems should also do more to help with follow-up and systematic oversight of feedback on diagnostic accuracy. “Clinicians need a reliable, automatic follow-up system that goes beyond the provision of simple, one-size-fits-all instructions to ‘return in four months’ or ‘call if not better’,” wrote Schiff and Bates.
Physicians, members of their support staff and patients should be engaged in re-engineering documentation, with the goal of building a more distributed, reliable, and content-rich yet succinct and efficient system, the authors concluded. “Diagnosing illness is one of our most important professional responsibilities, and patients justifiably expect us to perform this difficult task well. Electronic documentation represents a pivotal tool that can help us to fulfill this responsibility.”
EHRs must be designed to enhance clinicians’ workflow and quality of care, according to Schiff and Bates: “We envision a redesigned documentation function that anticipates new approaches to improving diagnosis, not one that relies on the putative “master diagnosticians" of past eras.”
Systems developers and clinicians need to reconceptualize documentation workflow as part of the next generation of EHRs, and policymakers must lead by adopting a more rational approach than the current one, “in which billing codes dictate evaluation and management and providers are forced to focus on ticking boxes rather than on thoughtfully documenting their clinical thinking,” according to the authors.
Because information from patients’ previous clinical encounters and tests will be more readily available with EHRs, they could substantially improve clinicians’ knowledge about the patient.
“The problem of having too much information is now surpassing that of having too little, and it will become increasingly difficult to review all the patient information that is electronically available. However, one virtue of computerized systems is that they can display recorded information in various formats. Designers will need to leverage the ‘visual affordance’ capabilities of EHRs to facilitate aggregation, trending and selective emphasis or display of data so as to facilitate rapid judgments,” the authors wrote.
EHRs can also foster assessment by serving as a place where clinicians—and patients—document evaluations, “craft thoughtful differential diagnoses, and note unanswered questions.” Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient’s history and making assessments, and notes should be designed to include discussion of uncertainties.
Documentation of clinicians’ thinking must be facilitated by streamlined text-entry tools such as voice recognition. “Exam-room layouts, screen placement and workflow should be redesigned to enable patients and physicians to work together on the same side of the screen. Follow-up questions should be documented in ways that facilitate tracking and sharing with future providers and consultants.”
EHR systems should document evolving history and ongoing assessment, and electronic notes should follow an evolutionary paradigm—especially for chronic conditions, according to Schiff and Bates. “Putting this strategy into effect will require us to go beyond reflex criticism of copy-and-paste methods to a search for creative approaches based on functions such as annotation, tracking of changes, and threads that not only enable information to be carried forward but also allow it to be continuously refined and updated."
A better approach to managing problem lists is also needed. "The failure to effectively integrate problem lists into the clinician’s workflow has been one of the great failures of clinical informatics,” the authors wrote. Most EHRs today lack tools for easily reordering these lists and allowing specific providers to work selectively with a subset of problems, they said.
EHRs should ensure fail-safe communication and action when ordering tests and tracking results. “Better tools are needed to efficiently weave results management into EHR documentation and workflow and to link laboratory results to problem lists and medications,” the authors wrote.
Electronic systems should incorporate checklist prompts to ensure key questions are asked and relevant diagnoses are considered. Diagnostic checklists have so far been neither clinically helpful nor widely used, Schiff and Bates claimed, “yet human memory alone cannot guarantee that key questions will be asked and important diagnoses considered and accurately weighed.” Practical, evidence-based decision-support software and predictive models that automatically generate differential diagnoses, facilitating both documentation and decision making, would be a great help, they said.
Electronic systems should also do more to help with follow-up and systematic oversight of feedback on diagnostic accuracy. “Clinicians need a reliable, automatic follow-up system that goes beyond the provision of simple, one-size-fits-all instructions to ‘return in four months’ or ‘call if not better’,” wrote Schiff and Bates.
Physicians, members of their support staff and patients should be engaged in re-engineering documentation, with the goal of building a more distributed, reliable, and content-rich yet succinct and efficient system, the authors concluded. “Diagnosing illness is one of our most important professional responsibilities, and patients justifiably expect us to perform this difficult task well. Electronic documentation represents a pivotal tool that can help us to fulfill this responsibility.”