By Rakhal M. Reddy, MD MSHI ACHIP FACHE, EHR Association Liaison & Chair of the HIMSS Physician Committee

This is the fifth in a blog series highlighting the discussions from the 2022 EHRA & HIMSS Physician Committee Summit: Meaningful and Streamlined Documentation.

There is little doubt that documentation burden has been and will continue to be an evolving topic in healthcare and informatics over the next few years. The American Medical Association (AMA) has certainly made strides with coding guidelines that help decrease the burden of clinician notes becoming “data dumps” that capture every minute detail of a clinical encounter, regardless of that data’s relevance. Over the course of this series, we have examined the findings of our Summit’s discussion groups, which Dr. Brian Jacobs, Dani Nordin, and Dr. Bryan Bagdasian summarized.

The first breakout group was tasked with defining “The Ideal Note.” Dr. Jacobs shared the consensus opinion that notes should be concise, with information that is valued by all stakeholders. There was a desire to move towards APSO (Assessment, Plan, Subjective, Objective) notes to bring the most sought-after part of the notes to the forefront and avoid repetitive information. Essentially, the EHR does not need to be recreated in a clinical note, with every section representing data that resides elsewhere in the system. Finally, Dr. Jacobs summarized the individual and organizational barriers which put a spotlight on clinicians’ unfortunate perception of what an ideal note “should” look like (i.e. the more documented, the better) and “copy-forward” culture that bloats our notes.  

As shared in our fourth post, the second group opined on the consequences of digital transformation – de-energized providers who have lost the art of producing notes from the perspective of their relationship with their patients and increasing struggles with completed notes. The receipt of the ideal note, the group summarized, illustrates the aim to satisfy a core responsibility for any provider contributing to the patient’s care – meaningful and effective communication handoffs. With the growing demand — guided by regulatory concerns and the direction of the healthcare industry — for interoperability between disparate health IT systems, this need will become ever more important in the coming years.

The final group focused on the barriers that technology or EHRs throw in the way of creating or transmitting that ideal clinical note. Representatives from the EHR Association, the HIMSS Physician Committee, and a multidisciplinary representation of clinicians discussed the impact of EHR functionality in creating streamlined and concise documentation to share the details of a clinician-patient encounter.

Four main themes were specific to this third group’s discussion, although it must be noted that several other themes were identified that touched on what came out of the other two groups. First, EHRs simply need to be more usable. While “usability” can be viewed from various angles, for clinicians it is well-defined – fewer clicks, more intuitive interfaces, and efficient workflows to complete essential tasks such as chart review, ordering, and documentation. Further, user journeys and gold-standard training — for end users and for health IT administrators — should be well-defined and can ensure all end users are using these systems to their fullest. 

Second, the group asked EHR developers to “think like us” by aligning their functionality and content accelerators with best practice workflows. However, the ability to adjust to alternative workflows is critical to encompass every person on a care team. The group acknowledged the importance of EHR developers continuing to engage with their physician groups and implementing UX (user experience) methods to gain insights into understanding end users’ needs and providing solutions that meet them. Third, work with advocacy groups and collaboratively with regulators, payers, and healthcare organizations to help reduce EHR burden in general. 

There is little doubt that silos between the various actors involved in governing EHR software have helped to exacerbate documentation burden for clinicians. To address this, health IT developers should focus on helping clinicians meet payer and regulatory demands without leaving their workflow, and on eliminating duplicative or conflicting documentation needs from influential parties. 

Finally, the group noted the need to look to the future with artificial intelligence and machine learning on the horizon. Although challenging to implement in healthcare organizations with limited resources, keeping our eyes on how these tools can help ease the documentation burden should be kept in front, as early development in this space has shown great promise.

The HIMSS Physician Committee is committed to furthering our relationship with the EHRA in 2023 while engaging with other groups to tackle the documentation burden issue and avoid duplicative work.