Clinical content refers to the various checklists, documents, and forms that address an area of medicine when using an EHR. For example, a pediatric practice would be interested in documentation tools for a newborn visit. Not all EHRs have clinical content for all areas of medicine. For example, some EHRs have clinical content for internal medicine, but lack the details needed for dermatology or cardiology.
A disturbing number of practices have failed to analyze the clinical content of their EHR and are distributing exam documents and other information that do not adequately or accurately document patient care. In the more serious situations, EHR clinical documents misrepresent the care provided and the patient’s condition. For example, one practice was distributing exam notes that had inappropriate gender information for all patients. In another situation, a specialist included extensive ROS information on the patient’s cardiovascular system which was not performed and not the specialist’s area of expertise. Such problems could precipitate a wide array of care, insurance, and medical professional liability issues.
These documentation errors and misrepresentations are a direct result of the nature of EHRs and how many practices initiate their use. As a practical matter, many physicians are concerned with the level of effort needed to complete documentation for a patient. With the best of intentions, many vendors offer extensive out of the box forms and features to speed adoption and documentation. For example, some EHRs generate an extensive note from a single “click.” Other tools may allow you to cite forward information from a previous patient note, or bring in a standard note that documents what you would expect to do for a patient with a particular problem.
The physician proceeds to “chart by exception”, or modify the note to document a particular encounter. These strategies are analogous to the standard dictation templates that many physicians use with their transcriptionists.
However, EHRs differ dramatically from transcription since many physicians and staff are not familiar with what is happening in the computer and how information is presented to patients. For example, when a note is cited forward, or a template note brought into the patient encounter note, the physician does not necessarily see all of the information or findings that were added to the patient’s note. These out of sight findings may cover services that may not have been provided or appropriate. As important, many EHRs do not indicate which findings were brought into the note versus information that was entered by the doctor. One would have to review all of the screens and information without any indications of information that you have entered or even reviewed.
Generation of exam notes and other documents can further obscure the physician’s intent. For example, many EHRs have scripts that pull information from the entered items and generate the exam note, referring doctor letter, disability certification or other document. Any change to the input of information, or the script that produces the document could affect the presentation of information. For example, a change to the script could programmatically derive a statement that was not explicitly recorded by the physician. In cases where additional information was entered into the standard template, the practice would have to modify the script for the information to be presented on the produced document. Otherwise, some EHR information would not be included in the printed note.
Regardless of whether you are installing or using an EHR, the practice needs to carefully evaluate clinical content before adoption and use:
Verify clinical content. Physicians need to train on and verify the clinical content by patient problem or service before they serve patients. The doctors should practice with previous services and verify that they can document the patient service as well as review the representations on the printed documents. In some cases, physicians have discovered information on the note that were not the result of entered items, but were added by the script that produced the exam note.
Manage production data. In some cases, physicians have used test templates and obsolete forms to document patient care. Staff and physicians need to protect the production database from any “test” templates or other setups that could be accidentally used to document patient care. Indeed, practices should not mingle their production setups and scripts with any test setups.
Implement quality assurance. Doctors and staff need to check the letters and other documents that are being produced from the EHR. In many cases, the information is entered in the patient chart, but the note produced from that information is not reviewed. Unlike transcription, the person generating the visit note or letter may be the only person from the practice that will ever see that document before it is send t o a patient or other healthcare organization.
Reverify clinical content. Changes to clinical content or scripts that produce documents should trigger a new verification of the clinical content as well as training physicians and staff on the changes.
EHRs can assist in the documentation of patient care and offer a wide range of benefits to physicians and patients. However, physicians and staff need to make sure that they protect and manage the clinical content foundation of their EHR as well as understand the implications of the clinical content on the documents that they produce. Otherwise, practices may be sending exam notes and other documents to patients that do not fairly and accurately represent the quality or standard of care.