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The Clinical Documentation Conundrum

By smace@healthleadersmedia.com  
   February 01, 2017

Others studying the clinical documentation inconsistency problem agree physician complaints are real. "It bothers me when physicians say, 'I don't trust the medical record anymore,' " says William R. Hersh, MD, professor and chair of the department of medical informatics and clinical epidemiology in the School of Medicine at Oregon Health & Science University in Portland. "They don't know if this note's been copied and pasted from an earlier medical record or another patient's medical record. They don't know what the patient's story is, because the previous doctor had to click all these boxes to fill in these forms."

"It's not just about the technology. It's about how we communicate. I have physicians that tell me they don't really believe what's in the medical record anymore. I don't think there is turning back the clock, of going back to paper," he says.

The sheer amount of work it takes for physicians to check boxes and fill in structured clinical documentation fields in EHRs is becoming more and more well documented. Researchers from Weill Cornell Medical College and the Medical Group Management Association surveyed 394 physician practices nationwide in 2016 and found physicians and their staff averaged 15.1 hours per physician per week processing quality metrics—the equivalent of 785.2 hours per physician per year.

Hersh says the industry as a whole needs to address cost and burnout from clinical documentation, particularly as it moves to implement new models of care.

"Medicine is fundamentally an information science," Hersh says. "You see some of the news reports [such as in the September 2016 Annals of Internal Medicine that] physicians spend two-thirds of their time away from patients. The reality is that physicians always have spent a minority of their time with patients. Ten years ago it was writing notes in the chart. Today it's dealing with data and information. As we move to things like bundled payments, information becomes more important."

Although much of this does exist today in medicine, Hersh says the healthcare industry can still learn from other professions such as air traffic control and the military, where using precise language reduces variation and ambiguity in practice. "There's never going to be complete elimination of ambiguity," he says. "We do need to try to standardize as best we can, especially if we're going to see any kind of benefit from things like precision medicine."

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.


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