July 24, 2015 - MEDITECH's physician consultants meet on a bi-weekly basis to discuss leading industry issues, new MEDITECH products, implementation tactics, and more. As part of their team meetings, they also hold a regular "Journal Club" roundtable on relevant medical literature that impacts EHR vendors.
On June 17, the physician consultants convened to examine clinical documentation in the 21st century. Their discussion was based on this position paper by the American College of Physicians. Within the paper, the Medical Informatics Committee of the American College of Physicians “reviews clinical documentation in an effort to clarify the broad range of complex and interrelated issues surrounding it and to suggest a path forward such that care and clinical documentation in the 21st century best serve the needs of patients and families.”
A Clinical Document According to the American College of Physicians
Lead Physician Informaticist Dr. Steven Jones opened the meeting with the definition of a clinical document, as defined by the American College of Physicians: “A clinical document should provide a way to track a patient’s condition and the actions that were taken by members of the care team. EHR generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up," he said. “Technology should facilitate, not impede or complicate the documentation process.”
Evolving Processes and External Drivers of Clinical Documentation
Next, Dr. Jones presented the evolving processes and external drivers of clinical documentation:
Policy Recommendations
The discussion primarily focused on the American College of Physicians’ policy recommendations, and how physicians can meet those challenges. Many agreed there has to be payment reform before documentation habits will change. E&M coding drives a lot of documentation and “note bloat.”
Dr. Jeff Abrams, MEDITECH medical consultant, cited the history of documentation for dialysis as a cautionary example of how a change in a reimbursement model (and documentation to support that reimbursement model) does not necessarily produce better outcomes. Dialysis documentation was revamped at the request of Nephrologists, he pointed out; and as a result, it is now geared toward creating Kt/V measurements, which are used to quantify dialysis treatment adequacy. Yet, as Dr. Abrams noted, “Patient factors and cultural factors play a bigger role in reimbursement, in terms of achieving these Kt/Vs…” than does the documentation model. Despite attempts to align documentation with an assessment of the adequacy of dialysis, the documentation system and the patient outcomes do not correlate well.
Dr. Abrams said, “ICD-10 will start to give us billing data that describes patients well enough that we can actually start to move the dial [in terms of assessing patient outcomes]. For better or worse, our billing data is our best data.”
According to Dr. Jones, “It’s a cautionary tale. Beware. As our own professional organizations set the standards for documentation, they still may not lead us to improved outcomes. Our professional organizations need to be nimble, and the understanding of what is required for appropriate documentation demands a dynamic learning environment.”
Macros, Templates, & MEDITECH’s Web Platform
Dr. Laurence Spector, MEDITECH physician informaticist, briefly demonstrated MEDITECH’s new web platform. He explained, “The use of macros and templates is just a mechanism of expediting the time spent and the repetitiveness that is often found in the review of system and exam. The web platform allows you to create not just normals, but normals individualized to the physician, the specialty, and more importantly, to the patient.”
Thoughtful Review
The physicians agreed MEDITECH is always coming up with new and interesting technologies, and thoughtful review of the patient’s record is a large consideration in the design process. Dr. Jones showed a summary screen from MEDITECH’s web platform, and encouraged discussion around how widgets, the reference area, and other tabs in the chart meet the needs for thoughtful review.
Dr. Jennifer McKay, corporate medical information officer at Avera Health, said, “I like the idea of a thoughtful environment so I’m able to synthesize my thoughts around something that’s more meaningful. How does a memory get made? You study the patient to learn about the patient and then synthesize about a theory about how to get them better.”
“When we had paper, there’s a real biology to how memories get made,” Dr. McKay continued. “When we’re doing documentation in our current environment, we’re not biologically connected to the typing process. We are, however, connected to a pen, pencil, or voice; so where I think about this ability to thoughtfully learn, this is where I use my data. It’s not perfect, but it’s better than nothing. That’s what I like about the way the data is presented. It allows me to be thoughtful about what I need to do next. It’s an organic experience. Now I know something I didn’t before.”
Dr. Ahmed, MEDITECH medical consultant, concurred, “The information is clinically-organized; it makes sense.”
Takeaways & Conclusion
Ultimately, the Physician team agreed thoughtful review and advancing clinical documentation initiatives were vital components of successful patient care. Lively discussion proved there are many ways to work toward this universal goal.
For more information on MEDITECH's physician initiatives, please visit the Physician Connection.