Monday, August 31, 2015

Health care documentation is terrible. Here’s why.

Heath care documentation is done for three reasons:
  1. health care delivery (that’s the obvious one)
  2. regulatory compliance (checking all the boxes our government and payers think are important)
  3. malpractice avoidance (no one wants to get sued)
These three categories actually apply to every task we do in health care, but let’s confine this discussion to documentation.
Note in the accompanying figure, our three basic health care work requirements fit logically into a Venn diagram. Much of what we do serves only one or two of the three driving purposes. In an ideal world, we work in the center of the diagram where all three converge. Unfortunately that “sweet spot” is pretty small, especially when it comes to documentation.
If all clinicians needed to do with our documentation was practice medicine (#1 above, blue in the attached Venn diagram), our notes would be more logical and much less bloated. Laundry lists of irrelevant and inaccurate diagnoses would not populate into every note. Copy and paste would occur a lot less often, and likely could be limited to appropriate uses such as carrying over past medical history (which should always be copy and pasted after verification to reduce errors). Only relevant physical exam findings would be reported, so these would not be lost in a sea of normals. Useful information that is not valued externally, such as personal touches (i.e., a patient’s wedding anniversaries, achievements of their children) would have it’s own optimized workflow.

Regulatory compliance and malpractice protection, the #2 and #3 health care documentation purposes above, are responsible for the large majority of the drivel that shows up in our notes. Believe me, we doctors would all love to confine our work to health care delivery, but external forces box us into this uncomfortable place, and this creates junk documentation.

The result of trying to serve all of these missions results in the mess we have today. Health care IT expert Fred Trotter says that working with EHR is “like having a conversation with a habitual liar who has a speech impediment.”
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As I’ve diagrammed here, EHR serves all three basic functions, but not to equal degrees. EHR is designed for and sold to hospital administrators. Their first priority is business related (i.e., making sure the system runs efficiently and within the law). They work in the peach (regulatory compliance) circle. After the federal government stepped in with EHR incentives, meaningful use requirements created a set of requirements for the EHR companies that are about 90 percent peach-colored as well.
After satisfying the needs of administrators and the government, EHR vendors allot remaining resources to serving working clinicians seeing patients, as well as the patients themselves. This results in the lesser segment of EHR devoted to care delivery represented in blue...

EHR activities fundamentally service the task of regulatory compliance (the peach circle) as their primary mission. This satisfies both the hospital administrators and the government. Because all parties have limited resources, the contribution to the health care delivery circle suffers. Both hospitals and clinicians are interested in Malpractice Protection, so the green circle is served at of mutual self-interest, although EHR workflow only tangentially addresses this need.
Clinicians need mechanisms to streamline documentation so they can spend time with patients instead of in front of computer screens. Ironically, many of the efficiencies built into EHR to give clinician more time with their patients have become targets of disapproval for our regulators and critics. I find it frustrating when I hear pundits and government officials rally against copy/paste and templates (such as normal physical exam findings). Most of these critics have no perspective on running a busy clinic or inpatient service. It would be impossible to do our jobs without some degree of automation. Do you think the legal profession would consider eliminating templates and copy/paste? Do you think contracts and wills are written freehand each time? Ridiculous.

Good clinicians need to fight external forces to protect their ability to care for their patients. That means we need to devote the large bulk of our time and thoughts to working in the blue circle of health care delivery. That’s where our mission is served. The other two circles? We should click/copy/paste/dictate/template only what is necessary to prevent us from being sued, sanctioned, denied payment, or accused of poor quality. If we can do that efficiently, we can get back to taking care of our patients. One casualty of this appropriate triage is ugly documentation.

Folks need to stop confusing health care documentation with health care delivery. Those who grade and pay us give far too much weight to the former. Those actually taking care of patients know where to set their priorities.
Edward J. Schloss is a cardiac electrophysiologist who blogs at Left to my own devices. He can be reached on Twitter @EJSMD.
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