Electronic Health Records

Adoption & Implementation News

ACP Offers EHR Clinical Documentation Improvement Guidelines

By Stephanie Reardon

Long trails of information can lead to difficulties in finding and understanding the most important information within a patient’s records at the point of care.

- The American College of Physicians (ACP) has released a report detailing recommendations for EHR clinical documentation improvement and best utilize technology to improve patient care and provider sharing.

A byproduct of increased physician EHR use is that it has simplified the process of practicing defensive medicine by allowing  providers to maintain more detailed documentation and avoid cases of alleged malpractice brought against them by patients. However, these long trails of information can also lead to difficulties in finding and understanding the most important information within a patient’s records at the point of care.

In response to this overcrowding of information, the ACP has recommended several policy changes to support proper clinical documentation.

“The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication,” the first rule of the report states. The need for this rule appears unnecessary, but sifting through extra details caused by practicing defensive medicine often leads to confusion for the next provider reading the document. Previous notes can be unnecessarily included in updated notes, straining a physician’s ability to locate the most important information.

In early 2014, the American Health Information Management Association (AHIMA) voiced its disapproval of copying and pasting information in EHRs. According to the group, this practice of cloning with an EHR creates the risk of significant errors or the perpetuation of outdated information.

Another key ACP recommendation is the need for physicians to define professional standards for their specific organizations and to facilitate a standard through collaboration with other providers. The report further details what physicians should make available when putting their EHR documentation standards in place:

  • A detailed version of the patient’s story
  • Previously documented clinical information

In order to keep EHR reporting up to date with modern use and technology, the ACP has also recommended changes to the EHR system design:

  • EHR developers should update EHR systems to allow for long-term care as well as care that incorporates teams of providers
  • Documentation in EHR systems should support a physician’s thought processes while they are documenting
  • EHRs should support the ability to link original information sources
  • Developers should limit the number of checkboxes a user has to click, especially in cases where previous documentation already indicates the information
  • Systems should allow for the inclusions of patient-generated data

“Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach, to the detriment of patient care.,” the report concludes. “Cooperation is needed among industry health care providers, health care systems, government, and insurers to continue to improve the documentation. We must work together to fundamentally change the EHR from a passive recipient of information to an active virtual care team member.”