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ACP seeks reform of electronic health record systems

The American College of Physicians called for ways to streamline lengthy electronic health records and clinical documentation in a new position paper.

“We are in danger of repeating history by overstructuring the clinical record and overloading it with extraneous data,” Thomas Kuhn, MA, and other members of the Medical Informatics Committee, wrote in the paper. “Physicians must learn to leverage the enormous and growing capabilities of [electronic health record] technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitable influence the way we think and teach, to the detriment of patient care.”

Current electronic health record (EHR) systems coding and regulatory requirements require excessive coding and documentation that make records less clear or concise, according to the researchers.

“Creative solutions to improve and simplify clinical documentation will be difficult to introduce because current documentation is driven by the need to support billing and comply with regulatory and coding requirements,” they wrote. “Regulations should be clear and should address clinical workflow without adding burden for documentation solely for the purpose of obtaining reimbursement.”

They suggested physicians and their organizations develop their own unique standards for clinical documentation that emphasize clarity and conciseness. This could include retelling the patient’s story in detail, using appropriate macros and templates as needed, thorough reviews of patient records for completeness and not copying or pasting information from one record to another to ensure accuracy. They also recommended ways to search EHRs more easily with links to content from prior entries and embedded tags to identify original sources of information.

“Cooperation is needed among industry health care providers, health care systems, government and insurers to continue to improve the documentation,” the researchers wrote.

Disclosure: The researchers report no relevant financial disclosures.