By Brian R. Jacobs, MD, FHIMSS (eClinicalWorks)

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

When the EHRA and the HIMSS Physician Committee came together for a virtual Summit on meaningful and streamlined clinician documentation, three multidisciplinary breakout groups addressed key issues related to the topic. These included the ideal clinician note and barriers to creating such notes, which is the focus of this blog, as well as the exchange of the ideal note between providers and barriers to such exchange, and the specific EHR-related barriers to creating and/or consuming the ideal note. 

As noted in Documentation Burden: Addressing the Elephant in the Room, few disagree “that the focus of the note should be on the clinical encounter and ensuring the information entered clearly captures the problem, medical decision making, and ultimately help with communication between clinicians and our patients while meeting coding and regulatory compliance requirements.” To continue this theme, this third blog will highlight the findings of the first Summit breakout group – which included physician, nursing, informatics, and EHR vendor representatives – discussing the topic of creating the ideal note, as well as the various barriers to creating that ideal note.

In our two previous articles, we described an “as-is” exercise with the EHRA workgroup and the HIMSS Physician Committee members where one issue became the focus: the flexibility of workflows. This series of blog posts reviews the results of the exercise and describes a path forward. So far, this series has covered Learning the EHR, Personalizing the EHR and Understanding the Patient. In this article we discuss the fourth and final topic that was raised: Providing Care.

Providing Care
Providing medical care for the patient necessitates “last mile” flexibility that allows clinicians to jump in and out of the expected workflow. It has been demonstrated that a defined “workflow” that physicians agreed upon during development most commonly erodes after the first several steps. (1,2) The ability to step back into the workflow after a short detour needs to be readily available in an intuitive and simple manner. There should also be flexibility in how the EHR is used, both to conform to an individual’s working style as well as to respond to the demands of a clinical situation. Along these lines, but not limited to them, is the ability to have more than one patient record open with safeguards that ensure the correct data is always entered into the right patient’s chart.