Physicians need to take control of technology.
EHR documentation can be dictated by billing rules and legal requirements, or by your need to describe your patients and provide quality care, according to the New England Journal of Medicine.
"Clinicians need to take back ownership of the medical record as a tool for improving patient care; such a move could have many benefits, including reducing the frequency of diagnostic errors," according to authors David W. Bates, MD, and Gordon D. Schiff, MD.
Increasing physician efficiency and improving patient care may be possible through the use of EHRs—but a system lacking the right capabilities can hinder the process. For this reason, physicians may want to weigh in when it comes time to adopt new technologies or upgrade older systems at their organizations.
Consider diagnostic errors.
"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," according to Bates and Schiff.
They believe physicians can use EHRs to access and display data from patients' prior clinical encounters and tests. Access to this information will improve their knowledge and facilitate rapid diagnostic judgments.
EHRs can also help physicians order and track tests, particularly when these functions are included with clinical documentation, according to the study. Physicians may want to press for systems that merge results management and documentation.
In addition, EHRs can (and should) use diagnostic checklists to facilitate documentation and decision-making and limit the chance of memory lapses.
And speaking of lists, Bates and Schiff believe EHRs can help physicians manage (e.g., update, create, and deactivate) problem lists. However, EHRs need to promote easier list management.
"Although such lists are vital for ensuring that important problems are not overlooked, clinicians will not maintain them unless they are made more useful and easier to incorporate into clinical conversations and documentation," they say.
Clinicians also need a place to document free-text narratives in their EHR to capture uncertainties, according to the NEJM article. They need to be able to "craft thoughtful differential diagnoses" and "note unanswered questions." And they need to be able to share the information with patients, consultants, and other healthcare providers. EHR systems also need to enable evolutionary documentation. Physicians should be able to update their patients' narratives, creating a well-documented history and ongoing assessment. This will be particularly beneficial for patients with chronic conditions.
"Systems developers and clinicians will need to reconceptualize documentation workflow as part of the next generation of EHRs, and policymakers will need to 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 Bates and Schiff.
At the end of the day, while the systems have to meet the needs of HIM, compliance, and finance departments, they also need to work for the clinicians.
Andrea Kraynak, CPC, is senior managing editor of Medical Records Briefing and HIM Connection. She may be reached at akraynak@hcpro.com.