EHR documentation challenges remain

Thomas Payne, MD, FACP, attending physician in the General Internal Medicine Center at the University of Washington Medical Center-Roosevelt in Seattle, dictates notes into a recorder between patient appointments, recording notes on one patient before seeing the next.

He then uses speech-recognition software to move those recorded notes into his electronic health record (EHR) system.

Payne said his system ensures he gets to his notes quickly after each visit, and saves him time. “I do leave the clinic sooner than my colleagues do, by 30 minutes or so,” he said.

Although Payne acknowledged that his process “might not be the right choice for every primary care provider,” he does see an overall need to develop better practices around documentation.

“Documentation is one of the most time-consuming parts of a doctor’s day, particularly in primary care. It’s an area ripe for improvement,” said Payne, who is also medical director for IT services at the University of Washington School of Medicine and board chair for the American Medical Informatics Association (AMIA).

The rapid rise of EHRs has brought with it both changes and challenges in how physicians record and share their patient notes. Leaders in the medical community have found that when it comes to aiding documentation, the systems need to do a better job.

The Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs cited the need for EHRs to “simplify and speed documentation,” through other members of the care team entering the information, automatic data capture by devices or other information systems, and even having patients enter data themselves.

Payne said most EHRs aren’t designed to support documentation in a way that works well for physicians and their staff.

For example, he said many doctors record their notes in narrative form, writing down information that while not necessarily related to what brought a patient in for that particular visit is important to document the patient’s overall well-being.

However, Payne said most EHRs want doctors to check boxes or use drop-down fields to add details about a patient; EHRs generally can’t take the information recorded in narrative form and use it to populate the preset fields. That means doctors recording the same information multiple times, moving from one field to another on their computer screens.

“That’s not particularly satisfying nor is it the best use of that physician’s time,” Payne said.

Next: Opportunities for improvement

Opportunities for improvement

The Accreditation Association for Ambulatory Health Care (AAAHC) in its Quality Roadmap 2016 also singled out issues with documentation, saying it’s an area that offers opportunities for improvement.

Cheryl Pistone, the AAAHC’s clinical director for ambulatory accreditation said the organization found that a physician’s EHR frequently didn’t have documentation from external providers nor did it always have enough information in particular circumstances. Namely, EHRs did not contain enough documentation on patients’ allergic reactions to medicine nor did they contain updated medication information. Additionally, EHRs do not always contain adequate details on small procedures, such as removing a small growth, done by physicians in their offices.

Pistone said EHRs should be configured to require physicians to add details about allergic reactions and then automatically populate that information in the multiple places within the medical record where it is needed.

EHRs should also be configured to enable doctors to easily enter information in narrative form. Then the EHR should use artificial intelligence (AI) and analytics to populate, parse and present data for physicians when and where they need it, Payne said.

Payne pointed out that leading EHR vendors as well as other software makers are developing and beginning to deploy more of these technologies, while technologies that support interoperability, such as the growing use of the Fast Healthcare Interoperability Resources (FHIR) standard, are speeding advancements on that front.

Improvements are long overdue, experts said.

 “Documentation is a great example of where a problem exists today and where the pace of technology improvements is not as great as everyone hoped,” said Payne.