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.  

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: