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The Physician Waiting Game (Room): Documentation Burdens Mount for Clinician Leaders

November 17, 2015
by Rajiv Leventhal
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As EHRs have become commonplace, physicians are left wondering when documentation within them will become simpler

On May 29, the EHR-2020 Task Force of the American Medical Informatics Association (AMIA) issued a report with recommendations on the status and future directions of electronic health records (EHRs). In the report, several of the recommendations, including the very first one, target cutting down on the amount and complexity of documentation clinicians have to do.

Undoubtedly, as more continues to be asked of physicians now than perhaps ever before, clinical documentation remains a huge burden for them. At the time of the task force report, Thomas Payne, M.D., medical director of IT services at University of Washington Medicine and chair of the task force, told Healthcare Informatics that the reason the report focused on that area is because it is causing a great deal of problems in practices. “Providers are very vocal in describing the burden this poses to them. And people who go to see those providers are also noticing that they don’t get the attention and focus that they used to,” Payne told HCI. “They see their doctor and nurse staring at a computer screen. It is lengthening the days of providers, interfering with the interaction that people have with providers and taking providers away from what they do best. That is why it is in the first set of recommendations.”

Indeed, the report’s first recommendation was to “simplify and speed documentation.” The report noted, “Although medicine requires an entire team to care for patients and to document the care patients receive, Centers for Medicare & Medicaid Services (CMS) requirements have placed the primary burden of office visit documentation on physicians. Information entered by other care team members and patients should be as valued as information entered by the physician.”

In a more recent interview with Healthcare Informatics, Payne expands on this thought, noting that other people, including patients, are qualified to enter information into the note. “The patients are the experts on how they feel that day, and other providers [other than the one in the room at the moment] are on the care team also,” Payne says. “They should be entering information that they know best and have that be sufficient for that part of the documentation. This way the burden is not solely on the provider who is in the room with the patient for that moment.” Payne’s driving point here, as outlined in the AMIA report, is that physicians’ time investment in patient care documentation has doubled in the last 20 years, by some measures, possibly consuming up to half of a physician’s day.

Technology Flaws

What’s more, the introduction of EHRs has only magnified these problems and the amount of time providers spend on documentation, Payne says. In one large survey, the task force noted, staff internists reported that EHRs take an extra 48 minutes of their time per day compared to manual systems.

Indeed, while EHRs can facilitate and even improve clinical documentation, their use can also add complexities and challenges. The “single most common issue that most physicians and other providers have about the current EHR state today is documentation,” Payne says. He gives an example of when a cancer screening is needed. He says that often the documentation for the screening—that has occurred somewhere else—is entered by the provider in the exam room when it could have flowed from the source of the screening test directly into the EHR without any requirement for re-entry. “We need to return the patient visit to its value, which is to listen to a person’s concerns, perform the relevant exam, and take the relevant history down,” Payne says.

Thomas Payne, M.D.

At the same time, many physicians have argued that the quality of the systems being used for clinical documentation is inadequate. To these points, earlier this year, the Medical Informatics Committee of the American College of Physicians (ACP) outlined seven recommendations related to clinical documentation within EHRs and five suggestions related to EHR design. While many of the ACP recommendations are broadly based, atop its list was that “patient care support and improvement of clinical outcomes should be the primary focus of clinical documentation software.”

Additionally, when the American Hospital Association (AHA), in conjunction with Newtown Square, Pa.-based Executive Health Resources, part of the Optum family, launched a Clinical Documentation Improvement Trends Survey in February 2015, one of its main findings was that the design of some EHRs can turn a physician encounter into an exercise in data entry. Also, the survey found, there are often patient details that are crucial in accurately representing the complexity of a case and delivering quality care but that don’t neatly fit into one of the EHR’s fields. This design flaw in EHRs can unintentionally prevent that crucial information from being documented in the patient’s medical record and instead just noted in the physician’s mind. Advancements in technology that leverage natural language processing and computer assisted coding can be an effective solution to address the documentation gaps prevalent in EHR systems, according to the report.