Documentation Burden: Receiving the Ideal Note

Dani Nordin (athenahealth), Chair, EHRA User Experience Workgroup, and Bryan Bagdasian, MD, MMM (MEDITECH)

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

While the ability to create an ideal clinical note is obviously important to the delivery of healthcare, equally essential to the process is the ability for other providers and systems — as well as the clinician’s future self — to use those historical notes to understand the patient’s history and inform future care decisions.

In our second breakout session, we focused on the problem of receiving and comprehending clinical notes received from others. Participants in the group included a mix of behavioral health specialists, hospital nurses, and informatics experts, including representatives from multiple EHR vendors. Using a combination of verbal prompts and a live-updated Mural board, we facilitated a discussion to answer the following questions:

(more…)

The Ideal Clinician Note and Barriers to its Creation

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.

(more…)

Documentation Burden: Addressing the Elephant in the Room

By Rakhal M. Reddy, MD MSHI ACHIP FACHE (Adventist Health), EHR Association Liaison, HIMSS Physician Committee

This is the second in a blog series highlighting the issues and solutions that emerged from the 2022 EHRA & HIMSS Physician Committee Summit: Meaningful and Streamlined Documentation.

Documentation burden as a topic has been sliced, diced, and cooked by various organizations, and as in the story of three blindfolded men describing an elephant – everyone seems to have a different perspective based on their assessment. Although there is general agreement as to the problem and some agreement as to the causes of documentation burden for clinicians, it is interesting to see how the different groups have viewed and proposed solutions for the elephant in the room.

Ultimately, there can be little argument 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.

(more…)

Meaningful and Streamlined Documentation

An Overview of the EHRA & HIMSS Physician Committee Summit 2022

By Hans Buitendijk (Oracle Cerner), Chair, EHR Association 

A key role of the electronic health record (EHR) is to enhance clinical decision-making and enable clinicians to plan and document patient care – information that is then communicated with other systems. But there are challenges that impede the EHR’s ability to fulfill that role to its fullest extent. These challenges and proposed solutions were the focus of the 2022 EHRA & HIMSS Physician Committee Summit: Meaningful and Streamlined Documentation.

Whereas the 2021 Summit focused on the state of clinical notes – including publication of best practices for drafting ideal notes – this year’s event focused on challenges inherent with EHRs and documentation. These challenges fall into the categories of clinical, quality reporting, operational, billing, regulatory, and registry requirements, as well as ease of documentation, ingesting and integrating data, and achieving meaningful decision support. In short, there is a wide range of often overlapping or conflicting requirements that EHRs need to address while enabling clinician users to enhance their clinical decision-making and plan and document patient care – but challenges stand in the way. 

(more…)

2022 Clinical Workflow Flexibility Challenges in the EHR: Defining the Problem (Part Three)

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.

(more…)

2022 Clinical Workflow Flexibility Challenges in the EHR: Defining the Problem (Part Two)

In our 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 that exercise and describes a path forward. This article will focus on the second of the two topics: Personalizing the EHR and Understanding the Patient.

Personalizing the EHR
A common thread for “personalizing the system” is that while there are often tools available to personalize and configure the system, they can be difficult to discover, challenging to scale and share, and overwhelming to interact with in the clinician workflow. If it were simpler to personalize or optimize one’s own EHR experience, there would be little need for an organization to conduct optimization exercises after the initial implementation. After spending eight or more hours in formal training, and then significant time post go-live with practical EHR use, having some simple means available for self-configuration might remove additional hours of optimization, which will in turn reduce physician frustration.

(more…)
  • Categories

  • Follow EHRA on Twitter

  • Enter your email address to follow this blog and receive notifications of new posts by email.

    Join 178 other subscribers
  • Contact Us

    Kasey Nicholoff
    staff @ ehra.org

    Amanda Patanow
    Communications and Media
    ehracomms @ npccs.com