A wish list for improving clinical documentation

“We want to do more than just adjust to a suboptimum system,” said Gordon D. Schiff, MD, associate director of the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital in Boston.

Schiff spoke during the fifth in a series of webinars on health IT and patient safety focused on the challenges of clinical documentation. The Office of the National Coordinator for Health IT sponsors the programs.

EHR users are told they will get familiar with the system, establish new workflows and learn tricks and shortcuts, but Schiff said that’s not good enough.

Clinical documentation, part of these EHR systems that users are finding challenging to navigate, is failing in myriad ways and in ways both apparent and less visible Schiff said. The added time for charting subtracts time from hands-on caring for patients and an associated “degrading pride in workmanship,” he said. That is contributing to the “demoralization of primary care,” he added.

Schiff discussed the functions that redesigned clinical documentation needs to fulfill:

• Reflect, record physician's thinking
• Documentation should be interactive
• Information can be input one way, displayed another
• Aid to synthesize, organize history and course of treatment
• Identify and understand changes over time
• Support cognition, decrease physician’s memory burden
• Prevents overlooking of problems, premature closure of diagnosis
• Help overcome rather than increase fragmentation
• Redesign for reliable communication, follow-up

There is another significant list of unmet requirements Schiff discussed:

• Problem lists need to be prioritized, organized, integrated
• Reliable, continuously updated family history, genetics
• Incorporation of patients’ social questionnaires into history
• Enriched, omnipresent social history
• Drive proactive, reliable plan and follow up
• Visual affordances for cognitive support
• Rapid access to information while writing note
• Support physician decision-making
• Real integration of voice integration

One of Schiff’s crusades, he said, is real-time support for health IT users. He also hopes healthcare will realize the role for voice recognition since the technology has improved leaps and bounds in the past few years. He also looks forward to proactive problem and error reporting and better learning from observation and testing. Reconception, design, evaluation and electronic metrics are all needed to redesign needed functions, he added.