Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation

Summary

In 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste documentation, because it not only simplifies the documentation process generally, but also supports meeting coding and regulatory requirements specifically. Since the primary goal of our profession is to spend as much time as possible listening to, understanding and helping patients, clinicians need information technology to make electronic documentation easier, not harder. At the same time, there should be reasonable restrictions on the use of copy and paste to limit the growing challenge of ‘note bloat’. We must find the right balance between ease of use and thoughtless documentation. The guiding principles in this document may be used to launch an interdisciplinary dialogue that promotes useful and necessary documentation that best facilitates efficient information capture and effective display.

Citation: Shoolin J, Ozeran L, Hamann C, Bria W. II. Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation. Appl Clin Inf 2013; 4: 293–303

http://dx.doi.org/10.4338/ACI-2013-02-R-0012

Keywords

Clinical documentation - inpatient clinical notes - documentation process - information capture - SOAP - APSO note - copy-paste - note bloat

 

Conflict of Interest

None

• References

• 1 Dunn J. Tour Egypt. Imhotep, Doctor, Architect, High Priest, Scribe and Vizier to King Djoser. Available from: www.touregypt.net/featurestories/imhotep.htm
• 2 Colgan R. Imhotep: The Physician/Architect Who Led Us From Magic to Medicine (2655-2600 B. C.). Available from: www.consultant360.com/blog/imhotep-physicianarchitect-who-led-us-magic-medicine-2655-2600-bc
• 3 Doll JA, Arora V. Time spent on clinical documentation: is technology a help or a hindrance?. Arch Intern Med 2010; 170 (14) 1276.
• 4 Weed LL. Medical records that guide and teach. N Engl J Med 1968; 278 (12) 652-657.
• 5 Hahn JS, Bernstein JA, McKenzie RB, King BJ, Longhurst CA. Rapid implemementation of inpatient electronic physician documentation at an academic hospital. Appl Clin Inform 2012; 3 (02) 175-185.
• 6 Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. J Am Med Inform Assoc 2004; 11 (04) 300-309.
• 7 Hirschtick RE. A piece of my mind. Copy-and-paste. J Am Med Assoc 2006; 295 (20) 2335-2336.
• 8 Hartzband P, Groopman J. Off the record - avoiding the pitfalls of going electronic. N Engl J Med 2008; 358 (16) 1656-1658.
• 9 O’Donnell HC, Kaushal R, Barron Y, Callahan MA, Adelman RD, Siegler EL. Physicians’ attitudes towards copy and pasting in electronic note writing. J Gen Intern Med 2009; 24 (01) 63-68.
• 10 Wrenn JO, Stein DM, Bakken S, Stetson PD. Quantifying clinical narrative redundancy in an electronic health record. J Am Med Inform Assoc 2010; 17 (01) 49-53.
• 11 Gelzer R, Hall T, Liette E, Reeves MG, Sundby J, Tegen A, Warner D, Wiedemann LA, McCormick K. Auditing copy and paste. J AHIMA 2009; 80 (01) 26-29.
• 12 Department of Health and Human Services, Centers for Medicare & Medicaid Services.. Evaluation and Management Services Guide. Baltimore, MD: Medicare Learning Network; 2010 Dec. ICN: 006764. Available from: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
• 13 Hyman D, Laire M, Redmond D, Kaplan D. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics 2012; 130 (01) e211-1219.
• 14 Williams CA, Mosley-Williams AD, Overhage JM. Arthritis quality indicators for the Veterans Administration: implications for electronic data collection, storage format, quality assessment, and clinical decision support. AMIA Annu Symp Proc 2007: 806-810.
• 15 Dimick, Chris. Documentation dad habits: shortcuts in electronic records pose risk. J AHIMA 2008; 79: 40-43.
• 16 Rosenbloom ST, Crow AN, Blackford JU, Johnson KB. Cognitive factors influencing perceptions of clinical documentation tools. J Biomed Inform 2007; 40 (02) 106-113.
• 17 American Medical Informatics Association Health policy meeting: the future state of clinical data capture and documentation. Washington, DC: AMIA; 2011. [updated Dec 6, 2011]; Available from: amia.org/sites/amia.org/files/AMIA-Policy-Meeting-2011-Final-Briefing-Book-12-08-2011.pdf.
• 18 Health Information Management Systems Society.. HIMSS usability task force: EHR usability 101. Chicago, IL; 2012. Available from: http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=559.
• 19 Cuvo JB, Dinh AK, Fahrenholz CG, Fletcher AJ, Howrey LM, Levinson SR, Washington L. Quality data and documentation for EHRs in physician practice. J AHIMA 2008; 79 (08) 43-48.
• 20 Feblowitz JC, Wright A, Singh H, Samal L, Sittig DF. Summarization of clinical information: a conceptual model. J Biomed Inform 2011; 44 (04) 688-699.
• 21 Cusack C, Hripcsak G, Bloomrosen M, Rosenbloom ST, Weaver CA, Wright A, Vawdrey DK, Walker J, Mamykina L. The future state of clinical data capture and documentation: a report from AMIA’s 2011 policy meeting. J Am Med Inform Assoc 2012; 20 (01) 134-140.
• 22 Stetson PD, Bakken S, Wrenn JO, Siegler EL. Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9). Appl Clin Inform 2012; 3 (02) 164-174.
• 23 Pakhomov S, Bjornsen S, Hanson P, Smith S. Quality performance measurement using the text of electronic medical records. Med Decis Making 2008; 28 (04) 462-470.
• 24 Ahmed A, Chandra S, Herasevich V, Gajic O, Pickering BW. The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance. Crit Care Med 2011; 39 (07) 1626-1634.
• 25 Hayden SP, Oppedisano R, Breudigam M. Leveraging electronic medical record (EMR) systems along with other health information systems (HIS) to improve data capture and reporting for a surgical quality improvement program at a tertiary care institution and integrated health system. AMIA Annu Symp Proc. 2007: 970.
• 26 Roth CP, Lim YW, Pevnick JM, Asch SM, McGlynn EA. The challenge of measuring quality of care from the electronic health record. Am J Med Qual 2009; 24 (05) 385-394.
• 27 Bernstam EV, Hersh WR, Sim I, Eichmann D, Silverstein JC, Smith JW, Becich MJ. Unintended consequences of health information technology: a need for biomedical informatics. J Biomed Inform 2010; 43 (05) 828-830.
• 28 Hurst JW. The problem-oriented record and the measurement of excellence. Arch Intern Med 1971; 128 (05) 818-819.
• 29 Rosenbloom ST, Stead WW, Denny JC, Giuse D, Lorenzi NM, Brown SH, Johnson KB. Generating clinical notes for electronic health record systems. Appl Clin Inform 2010; 1 (03) 232-243.
• 30 Payne TH, tenBroek AE, Fletcher GS, Labuguen MC. Transition from paper to electronic inpatient physician notes. J Am Med Inform Assoc 2010; 17 (01) 108-111.
• 31 Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB. Data from clinical notes: a perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc 2011; 18 (02) 181-186.
• 32 Kaiser Health News HHS Fraud Squad Digging Into EHR Medicare Overbilling. Menlo Park CA. 2013 Available from: www.kaiserhealthnews.org/Daily-Reports/2012/October/26/health-it.aspx
• 33 Healthcare IT News Republican senators seek ways to improve HITECH implementation.. Chicago IL. 2013 Available from: www.healthcareitnews.com/news/repbulican-senators-seek-ways-improve-hitech-implementation