Reflecting on National Health Information Technology Week, I am reminded of how far healthcare has come and how many advances have occurred over the years. When I went to medical school, I brought with me a portable, 8-inch record player, a box of records, a typewriter and white out. This was state-of-the-art technology and it was great. Times were different then. While in school, I learned there were two major uses of the patient chart. The first was to help me keep track of what was going on with my patient, and the second was to provide basic information to my colleagues who would care for my patients in my absence. As a result, when I went into practice, my patient records consisted of brief notes, handwritten problem and medication lists, paper reports from laboratory testing, diagnostic studies and reports from other doctors.
Not long after that, healthcare insurers started to pay for office visits and my office notes became longer as I fulfilled the requirements to justify the bill for my services. The advent of electronic health records and Meaningful Use then required me to directly share my notes with other clinicians. And now, with stage II, yet another “customer” of the patient chart has been added – the patient.
Health records are now being viewed by several disparate, but equally interested parties, all sifting for different pieces of information and specific insight:
- For my colleagues: background information and patient history can prove invaluable in ensuring continuity of care;
- For my patients: progress notes and follow-up action items empower them to take control of their own health;
- For the clinical documentation specialists (CDSs): specific language that can be translated into ICD-10 codes is essential – after all, accurate documentation ensures proper billing, quality measures are met, compliance is documented, and doctors and the institution are reimbursed;
- For CFOs: data that can be culled and analyzed to generate reports on case mix indexes and population health breakouts can be used to improve care and keep quality patient programs running.
While all of this data is important, for the clinician, medical records are still about capturing the patient’s story. While I realize that these components are necessary for ensuring regulatory compliance and financial reimbursement, being asked to answer questions, provide more data points and document information that seems to be ancillary to the care I am providing to my patient is a point of frustration.
All of these different groups have the patient’s best health in mind, but there is an obvious need to provide doctors, like me, with the technology and tools to create useful, informative charts while simultaneously meeting all other requirements. For instance, I know that if I speak or type, I do a better (and quicker) job of telling my patient’s story than if I try to create my note by picking words, phrases, and concepts off a checklist. In fact, research shows that narrative notes do a much better job of communicating the patient story to other clinicians than lists created from checkboxes and drop-down menus.
From this narrative, clinical language understanding (CLU) software can parse my notes, pull key phrases and populate mandated EHR fields for me. Similarly, like a good colleague, computer-assisted physician documentation (CAPD) reads my narrative over for content and immediately asks me specific questions about anything that might be unclear, which means a CDS doesn’t have to track me down for further clarification. Technology takes care of the mandated details so we can focus on our patients.
As clinicians, we have worked tirelessly in a field where the evolution of knowledge takes place daily. What was considered “advanced” twenty years ago may now be outdated – as a student who shared one phone line with an entire college dorm floor, I never even dreamed I would one day be dictating my patient notes directly into a chart using a smartphone. And yet here I am.
Now that fall is here, first-year medical students across the country are packing up their smartphones and laptops, ready to learn how to balance the art of medicine with new technologies that will help them provide better patient care. The technology is evolving, but so are we.