Physician documentation: Let’s not solve one problem by causing another

May 19, 2021 / By L. Gordon Moore, MD

As part of a clinical improvement project, I was reviewing charts in a hospital and was dismayed by how much junk I had to wade through to find out what was happening. A person’s hospital chart tells the story of what’s going on and is a critical information source for the many hospital staff interacting with that patient.

In the bad-old paper days, I could flip to the chart of vital signs, quickly review the overnight nurse’s note, check for a consultant’s observations and recommendations. In the digital world, I have instant access to a lot more information, but it is much more difficult to understand what’s actually happening. 

This is partly due to user interfaces that can log me out if I take too long reading a particular page, and that are complicated and inattentive to standard design principles, but maybe mostly due to how EMRs are primarily designed to satisfy the billing functions of hospitals at the (unintended) cost of hindering the way clinicians work.

It is not necessary to solve one problem while causing another. It is possible to satisfy the billing enterprise AND the clinical workflow of taking care of patients. The monolithic EMR companies are working to improve their systems and there are companies figuring out how to work on top of the EMRs to solve the user interface problems while serving the billing and clinical workflows.

While smart tech tackles these problems, it would also be helpful to revisit the policies behind some of the problems. 

“We can easily eliminate 1 billion clicks a day,” said Dr. Sinsky, adding that her all-time high click count was the 32 clicks it took to record having ordered and administered an influenza shot. “I know we can do better than that,” she said.

I had a chance to speak with Christine Sinsky, MD, Vice President, Professional Satisfaction, AMA, and hear more about clinical documentation and burnout on 3M’s Inside Angle podcast.

Dr. Gordon Moore is Senior Medical Director, Clinical Strategy and Value-based Care for 3M Health Information Systems.