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The Clinical Documentation Conundrum

By smace@healthleadersmedia.com  
   February 01, 2017

"From 1984 on, evaluation and management coding has been a means for CMS and insurance companies to be able to pay doctors," Erskine says. "It's also been an enormous burden."

More and more, EHRs are helping physicians keep up with ever-growing clinical documentation demands, says Erskine. "When I write a note today, the computer really writes 75% of the note for me," he says. "It picks out certain templates, labs, and diagnostic imaging results. It may pull forward information that I had put in a note previously or that somebody else put in a note, and that becomes part of my new note."

While the computer-added information is a boon for analytics driving measures such as clinical quality reporting and population health initiatives, "the problem is we've lost a lot of the narrative in that note," Erskine says.

The ICD-10 transition also fell short of expectations, Erskine says. "It was dramatically overstated that somehow the doctors are going to be picking the right ICD-10-specific diagnoses, and we're going to have a much more robust and revealing medical record system," he says. "It wasn't that much of an issue for them before, and they're not really paying that much attention to it now."

In response, Geisinger has adopted a policy of not forcing its physicians to use a template when they write their notes. "If you want to just open up a [blank document] and start typing text, you're free to do so," Erskine says. "If you want to dictate your note and have that dictation turn into text, you're free to do so as well."

In addition to relying on ever-improving speech-to-text technology, Geisinger, in its role as an academic medical center, encourages its residents and medical students who encounter notes that do not make narrative sense to return the note to the author via the EHR's inbox function and ask the author to restate the note for better clarity, Erskine says.

Another approach that Geisinger and others have taken is to implement OpenNotes, a national movement for sharing the system's existing medical record notes with patients themselves, who are then encouraged to point out errors or additions, Erskine adds.

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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