American College of Physicians offers tips for better EHR system usage
When it comes to achieving meaningful use of patient information, selecting the best EHR software is essential. However, there’s more to it than choosing the right technology – providers must learn to embrace advancements in healthcare IT and properly use new technologies for the betterment of EHR usability and efficiency. That was the topic of discussion in a new paper published by the American College of Physicians in the January 2015 issue of the journal Annals of Internal Medicine.
The paper examines the evolution of clinical documentation in the current century – past advancements and indications of what’s to come. The authors note that existing technology like patient portals, registries and home monitoring devices are likely to be integrated into EHR systems in the future, and demand and feedback from physicians will be key in driving such improvements.
“We believe that physicians must help define and prioritize the many important roles that clinical documentation serves today,” the report’s authors wrote. “The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.”
Suggestions for using EHR software
The report also provided a handful of recommendations for providers, policymakers and IT developers in regards to enhancing EHR usage. When it comes to clinical documentation, physicians should understand that the main purpose is to deliver quality patient care and improve care outcomes. To do so, the ACP suggest that healthcare organizations implement these professional standards in their clinical documentation practices:
Patient records should include as much detail as possible required to retell the story without providing excess information unnecessary to the clinical process.
Templates and macros should be used in appropriate situations to help make documentation as complete and efficient as possible. This may be best suited for situations when records require only standardized terminology, such as when reporting physical exam results.
Clinician software training should be ongoing and exhaustive to keep providers up to date on new technologies.
During the medical document management process, the “review/edit: and “copy/forward” functions may be useful when clinical data is still relevant and accurate and any added information improves the accuracy and completeness of documentation; however, such functions should be used carefully as they can often weaken documentation.
Overall, the main goal of such suggestions is to avoid overloading EHRs with extraneous information that diminishes the value of patient records by allowing the important data to be lost win a bevy of unnecessary data. Keeping documentation direct, to-the-point and appropriately detailed can help ensure that you get the most out of your EHR software and in turn, can help providers deliver quality care for the betterment of both individual and population health.