Care-Centered Clinical Documentation in the Digital Environment: Solutions to Alleviate Burnout

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1 Cre-Centered Clinicl Documenttion in the Digitl Environment: Solutions to Allevite Burnout Alexnder K. Ommy, DSc, MA, Assocition of Americn Medicl Colleges; Pmel F. Ciprino, PhD, RN, NEA-BC, FAAN, Americn Nurses Assocition; Dvid B. Hoyt, MD, FACS, Americn College of Surgeons; Keith A Horvth, MD, Assocition of Americn Medicl Colleges; Pul Tng, MD, MS, IBM Wtson Helth; Hrold L. Pz, MD, MS, Aetn; Mrk S. DeFrncesco, MD, MBA, FACOG, Americn College of Obstetricins nd Gynecologists; Susn T. Hingle, MD, Americn College of Physicins; Sm Butler, MD, Epic; Christine A. Sinsky, MD, Americn Medicl Assocition Jnury 29, 2018 Introduction A rnge of fctors drives clinicin burnout, including worklod, time pressure, clericl burden, nd professionl isoltion [1]. Clericl burden, especilly documenttion of cre nd order entry, is mjor driver of clinicin burnout. Recent studies hve shown tht physicins spend s much s 50 percent of their time completing clinicl documenttion [2]. Nurses similrly spend up to hlf their time fulfilling clinicl documenttion requirements nd dt entry for other demnds such s qulity reporting nd meeting ccredittion stndrds [3]. In the outptient setting, ptients will often describe clinicl tem members going through mundne questioning nd computer documenttion, often duplictive, nd spending little time mking eye contct nd tlking to them, or performing physicl exmintion [4]. With the exception of improving mediction sfety, nurses nd other clinicins report disstisfction with the design nd cumbersome processes of electronic documenttion [5]. Mny clinicins feel they re compelled to first stisfy the demnds of documenttion in the clinicl record. After cring for ptients, mny clinicins devote significnt mounts of time to nonclinicl ctivities, which often crry on into fterhours. This pper explores the reltionship between clinicl documenttion, the electronic systems tht support documenttion, nd clinicin burnout, nd provides recommendtions for ddressing these issues. Bckground Clinicin well-being nd fulfillment in work is criticl for ptient sfety nd helth system function [6]. Fulfillment in work hs been scribed to three fctors: (1) mstery: competency nd proficiency in the work to be done, (2) utonomy: hving some element of influence over the wy work is performed, nd (3) purpose: connection to filling societl need in n environment where one s profession is honored nd vlued [7]. The current epidemic of clinicin burnout is relted to these fctors. Clinicins incresingly feel burdened by dministrtive tsks tht seem to not dd vlue to ptient cre nd re unrelted to the resons they chose their professions. The disconnect between one s clling nd one s dily work contributes to distress, nd cn led to liention, isoltion, depersonliztion, cynicism, emotionl exhustion, nd burnout. Clinicl documenttion begn when physicins recorded cse reports of ptient s course of cre [8]. These cse reports evolved into records used in teching others the prctice of medicine. Although the originl impetus for clinicl documenttion ws to tell ptient s story nd describe tht person s tretment nd progress, recent history hs seen n incresing shift towrd tiloring documenttion to fulfill billing requirements. Clinicl Documenttion nd Coding Requirements Severl mjor forces led to chnges in clinicl documenttion. First, s component of public funding Perspectives Expert Voices in Helth & Helth Cre

2 (Medicre nd Medicid), documenttion of services becme requirement for pyment, becuse federl pyers needed to ensure tht txpyer funds were ppropritely spent nd beneficiries received mediclly necessry services. Additionlly, pyers hd to gurd ginst frud. However, pyers re requiring incresingly detiled documenttion to provide reimbursement. Similrly, privte pyers hve incresed dministrtive oversight in the form of dministrtive prepprovl processes nd very specific documenttion criteri to reimburse for drugs nd procedures. These requests encourge the genertion of boilerplte text, templtes, check boxes, nd other documenttion tools tht fulfill billing purposes but cn produce documenttion of limited clinicl vlue nd lso dd time to the documenttion process [9]. Movement wy from detiled documenttion of ech cre process to focus on rewrding ptient outcome is potentilly beneficil. However, the mngement of the trnsition nd the specified documenttion pproches for outcome mesurement will directly ffect the potentil benefit. The second fctor influencing the chnge in clinicl documenttion ws computeriztion of the ptient medicl/helth record. Erly systems fulfilled the need to collect dt from different sources (phrmcy, lbortory, trnscription). These electronic helth records (EHRs) were often used to support billing nd collections, nd not necessrily clinicl needs nd workflow. Next, computerized provider order entry systems (CPOE) were introduced tht use described guidelines for cre nd checklists in the form of electronic order sets. CPOE offers dvntges over trditionl pperbsed order-writing systems, such s improved ccurcy in ordering services nd the voidnce of problems ssocited with hndwriting legibility. However, CPOE interrupts the trditionl workflow of order entry. The wy electronic order sets conceptulize workflow often does not lign with ctul prctice. For exmple, ICU physicins re often lerted to emergent needs for mediction orders by the bedside nurse, who monitors the ptient closely. Nurses were previously ble to write verbl orders from the physicin, with physicin signture lter, sometimes fter dministrtion of the mediction. In contrst, CPOE workflow requires the physicin to enter the order s well s sign it [10]. Further ttention to the design nd implementtion of CPOE is necessry to relize its full potentil benefits. The third fctor tht chnged workflow ws the introduction of ptient confidentility rules nd regultions within the Helth Insurnce Portbility nd Accountbility Act (HIPAA). Although HIPAA introduced importnt privcy protections for ptients, the lw lso led helth systems to limit the use of tools such s the problem-oriented checklist, nmes of ptients written on the rooms or centrl loctions, nd mny other bsic forms of communiction. A continued shortcoming of modern systems is dherence to tedious detiled documenttion requirements to stisfy pyers nd regultions. We hve yet to design systems to support the premise tht clinicl documenttion exists to support the cre clinicins deliver to ptients, nd other functions should be secondry gol. By creting specific tsk out of every element of informtion, even with the use of checklists nd reporting by exception, clinicins time is dversely ffected. In prt, this is perpetuted by the myth tht if it isn t documented, it wsn t done [11]. Much of this hs been driven by linking documenttion to pyment. This demnd hs perpetuted the perception by clinicins tht pyers do not fully trust them. The perceived overdocumenttion of process fuels resentment tht pyers re supplnting the clinicin s professionl judgment regrding the cre tht needs to be provided. Centers for Medicre nd Medicid Services Evlution nd Mngement (E/M) coding guidelines offer good exmple of the chllenges in completion of document requirements. E/M codes require ttesttion of vrious elements of the ptient s history, including review of 14 systems (e.g., respirtory) nd physicl exmintion to support the level of pyment requested. There re five levels of pyment, which re determined by tbulr interply of four levels of medicl history, four levels of physicl exmintion, nd four levels of medicl decision mking [12]. This results in bundntly detiled documenttion, which is necessry for billing purposes, nd, with the exception of medicl decision mking, is often cliniclly irrelevnt [13]. The EHR compounds this problem by fcilitting the collection of mny redundnt or irrelevnt detils. Another chllenge is tht some institutions over interpret E/M coding guidelines nd require tht only physicins cn directly enter elements of the History of Present Illness (HPI). In ddition, limittions re sometimes plced on cliniclly trined stff (medicl ssistnts or nurses) Pge 2 Published Jnury 29, 2018

3 Cre-Centered Clinicl Documenttion in the Digitl Environment such tht they must sign in nd out of roles between clericl nd clinicl tsks, nd tht the HPI drfted by n MA or nurse during rooming does not count for billing. Clinicl Informtion Systems EHRs provide nexus for informtion input nd retrievl mong complex helth cre systems nd environments. However, there re chllenges in the use of EHRs tht ffect clinicin burnout. The Helth Informtion Technology for Economic nd Clinicl Helth (HI- TECH) Act of 2009 provided the finncil support nd incentives to ccelerte the doption of computerized ptient records. Through the Meningful Use (MU) Progrm of HITECH, eligible providers nd orgniztions could grner significnt funding to offset the costs of implementing EHRs with the intention of optimlly using the dt to improve the ptient experience, s well s qulity nd cost of cre. The rpid pce of implementing systems tht were vilble on the mrket t the time discourged mny clinicins nd orgniztions from tking the time to redesign workflows, or insist on design chnges in EHR systems tht would better support clinicl cre. Wht ws not envisioned ws tht the electronic systems would exct more benefits for those other thn ptients nd clinicins e.g., utomted clims for third-prty pyers. Currently, most sites of clinicl cre use EHRs, which include electronic prescribing (phrmcy informtion systems) nd CPOE [14,15]. These systems often connect to clinicl decision support systems (CDSS), lbortory, rdiology, telehelth, mobile helth, ptient portls, nd helth informtion exchnge systems (see Figure 1). CDSS re designed to id clinicl decision mking by providing ptient-specific ssessments or recommendtions. When MU incentives rpidly dvnced the implementtion of EHR systems, it brought long the bredth of fetures listed bove. Also for helth cre providers, MU brought enhnced use of structured dt elements, nd significnt chnges in workflow. Although some positive process nd outcomes improvements hve been reported with the use of CPOE nd CDSS systems, the overll results re PACS Rdiol IS Lb IS Phrm IS Clims Other Providers HIE Clinicin CPOE Public Helth CDSS CDSS Clinicl Decision Support CPOE Computerized Provider Order Entry HIE Helth Informtion Exchnge IS Informtion System PACS Picture Archiving & Communictions System mhelth Ptient Portls Tele Helth Apps & tools Figure 1 Clinicin EHR Systems/Tools SOURCE: Ommy et l., Cre-Centered Clinicl Documenttion in the Digitl Environment: Solutions to Allevite Burnout, Ntionl Acdemy of Medicine. NAM.edu/Perspectives Pge 3

4 mixed [16,17,18,19,20,21]. There is evidence for enhnced qulity nd sfety, but there is lso risk tht distrctions cused by ssocited clericl burden cn contribute to sfety issues [20]. Physicins who do use CPOE experience 30 percent higher rtes of burnout thn those who do not [2]. Severl studies document tht physicins nd residents spend 50 percent or more of their time using EHR systems for documenttion, ordering tests, reviewing results, nd communicting with ptients or tem members [22,23,24]. Furthermore, nurses lso spend up to 50 percent of their time on documenttion [3]. From the erly inception of electronic documenttion, pproprite mechnisms to encourge direct clinicin input hve proved to be chllenge. CDSS often provide lerts (such s drug interctions nd reminders) to helth cre providers s they use the EHR. Efforts of helth systems to improve qulity nd performnce long with MU requirements hve led to widespred use of CDSS nd lerts. However, high percentge of lerts re routinely bypssed [25,26]. Another feture of EHR systems, inbox notifictions, lso consumes clinicin time recent study estimted tht physicins spend n verge of 67 minutes per dy processing these notifictions [27]. As result, the utility of such notifictions should be optimized nd wrrnts further investigtion. Personl helth records tht store helth dt input by the consumer or from other dt sources hve been implemented through vriety of models. They re most frequently vilble s tethered ptient portls in EHRs, but freestnding products re lso offered. However, doption of ptient helth records hs been slow, nd there re recognized brriers to their use [28]. Incresingly, mobile helth dt re vilble through personl mobile helth devices nd phones tht cn mesure hert rte, steps, oxygen sturtion, nd other dt. Integrtion nd use of this dt cn be importnt to ptient mngement, nd plys growing role in the clinicl record. Ptients nd clinicins benefit when essentil relevnt helth informtion is vilble t the point of cre. For this to occur, helth informtion must be shred cross systems. Helth informtion exchnge (HIE) efforts re focused on the problem of shring dt between EHR systems. Although progress is being mde, brriers remin with interoperbility between EHRs nd other helth informtion tools nd systems [15,29,30]. Also, there re concerns tht HIE is impeded by EHR products becuse informtion shring between systems cn be chllenging [31]. A principl chllenge in HIE is the limited stndrdized formtting of dt nd lck of common frmework [32]. Although it is common in other industries such s bnking nd trvel, this lck of esy exchnge of medicl dt constrins the overrching promise of EHRs. The digitl environment in helth cre hs irrevocbly chnged how clinicins deliver nd document cre. The promise of technology to deliver on improving cre nd outcomes, s well s enbling workflow nd reducing clinicin worklod, hs yet to be fully relized. The Ntionl Acdemy of Medicine (NAM) recognized the impending chllenges more thn two decdes go when it formed the Committee on Improving the Ptient Record in Response to Incresing Functionl Requirements nd Technologicl Advnces [33]. In their report, the committee cknowledged both the benefits nd the chllenges of the rpid expnsion of informtion technology in helth cre. As helth cre continues to become incresingly complex nd the pce of technologicl chnge ccelertes, the need to revisit the digitl environment in helth cre hs never been more pressing. System Chllenges in the Current Environment Clinicins must spend incresing portions of their work time on nonclinicl ctivities. This leds to lck of control over their workdy, loss of collegility while working in isoltion, nd interference with the ptientphysicin/clinicin reltionship s computer screen cretes physicl nd psychologicl brrier between them [34]. EHRs hve spwned new MD exercise known colloquilly s Pjm Time, with mndted documenttion crrying on into fterhours becuse of the volume of required computer tsks nd the bility to complete these tsks remotely. Becuse of the forementioned pyment guidelines nd the ese with which digitl documenttion llows copying nd psting or just dding to prior entries, the EHR hs become bloted repository of repetitive nd redundnt informtion. Recent studies indicte tht, in vriety of settings, clinicins routinely use copy nd pste or copy-forwrd nd tht most clinicl notes re the result of copied or imported text [35,36]. The ptient s story is further lost in the fog of self-populted content tht dds pges but little purpose to the notes [37]. Pge 4 Published Jnury 29, 2018

5 Cre-Centered Clinicl Documenttion in the Digitl Environment Another feture tht n EHR hs tht pper chrt lcks is the bility to use templtes nd menus. Depending on the use, these fetures cn either speed up or slow down use but my not necessrily improve content. Forced chrcteriztion by selecting choices from pull-down list or prewritten text prevents telling the story in the ptient s own words in s much detil s possible. Some helth orgniztions require documenttion through templtes (e.g., drop-down boxes) to fcilitte billing nd uditing. Optimiztion of templte design my help llevite some of these issues. The Chllenge of Multiple Stkeholder Requirements Driving Clinicl Documenttion The espoused dvntges of electronic helth records re to help provide higher-qulity nd sfer cre long with greter efficiency to meet business gols. Some of the potentil dvntges re widely ccepted: timely ccess to ptient records, legible documenttion, more relible prescribing, reduction of some error-prone processes, enhnced privcy nd security of dt, nd the potentil to shre informtion electroniclly with ptients nd other cre providers. The dvntges of other cpbilities re less certin nd hve yet to be relized by the mjority of ptients nd clinicins. These dvntges include better-coordinted nd efficient cre, enhnced clinicin nd tem communiction, complete documenttion for stremlined coding nd billing, improved productivity nd efficiency leding to better work-life blnce for clinicins, nd reduced costs with less pperwork s well s elimintion of duplicte dignostics. Given the investment nd desire to optimize the use of EHR systems, prctices nd orgniztions rely on the brodest possible ppliction of its use to service diverse rry of stkeholders, including but not limited to ptients, clinicins, institutions, pyers (public nd privte), vendors, reserch bodies, registries, regultory bodies nd regultory counsel, nd policy mkers. These stkeholders hve gret expecttions tht my lso crete competing interests. For exmple, documenttion methods tht cpture dt in structured formt cn help fcilitte billing or dt nlysis for qulity improvement. However, clinicins my prefer free-form methods tht provide greter flexibility nd my be fster thn structured templtes in certin instnces (though the use of structured formts nd free-form methods for clinicl documenttion re not mutully exclusive). Tht being sid, ll stkeholders rely on dt for criticl decision mking s well s dvncing business decisions. The fundmentl functions driving clinicl-documenttion demnds include trditionl recording of cre, utomted trnsctions, nd pproches to enble greter qulity, efficiency, nd informed decision mking s summrized in Tble 1. Leverging Digitl Helth to Support Rtionl Clinicl Documenttion Up to 80 percent of informtion bout n individul in medicl record is textul. Use of free text in clinicl notes is n importnt prt of medicl documenttion. It llows the clinicin to go beyond structured dt entry to record more holistic view of n individul. In ddition, under the Assessment nd Pln sections of progress note, clinicins describe their current ssessment, long with their rtionle, nd plns for next steps in dignosis or tretment. Reimgining the future of digitl helth informtion technology to support clinicins, ptients, nd personcentered cre relies on reevluting the current dt elements collected nd entries recorded in EHRs. Simplifying the bredth nd depth of documenttion for ll clinicins should be predicted on evidence tht the documenttion is justified. Providing Automted Review of Previous Clinicl Informtion With the introduction of EHRs, nd their text-productivity tools (e.g., templtes, mcros, nd copy-pste functionlity), clinicl notes hve become bloted nd difficult to red. This forces the next clinicin to go through process of forging to uncover importnt elements of pst notes. By pplying specilly designed nturl lnguge processing lgorithms, computers re now poised to red clinicl text nd glen importnt insights from it. Nturl lnguge processing (NLP) tools hve been shown to relibly extrct dt from clinicl notes with high levels of precision in reserch settings for specific tsks [38,39]. Current use of NLP lso llows clinicins to dictte clinicl experience nd cn provide structured dt without the use of templte. In study published in the Journl of Medicl Internet Reserch, use of dicttion plus NLP reduced documenttion time while mintining documenttion qulity [40]. Future tools tht fcilitte the presenttion of summry insights from the pst in succinct fshion NAM.edu/Perspectives Pge 5

6 Tble 1 Drivers of Clinicl Documenttion Functions Use/Purpose Should Be Prt of Clinicl Documenttion[] Recording of clinicin observtions, thoughts, nd ctions Ptient- nd mobile-technologygenerted dt Trnsctionl Dt-enbled prevention nd mngement of clinicl conditions (requires interoperbility nd HIE) Qulity improvement through dt cpture nd evidence synthesis Eduction Efficiency Decision mking enbled by dt Reserch Ptient nrrtive Dignosis Tretment/interventions nd response Plns of cre, consulttions Prescriptions for tretment, follow-up, mediction, etc. Generl communiction with ptient, fmily, nd cre tem members Ongoing lerning Inform cre tem Understnd person-centered cre expecttions Additionl dt cpture from devices, home monitoring, etc. Ptient enggement Coding nd billing (utomted clims processing) Qulity metrics reporting Helth informtion exchnge Regultory reporting for complince e-prescribing nd CPOE Noncommunicble diseses/ chronic cre mngement Mngement of trnsitions of cre Anticiption of prevention efforts nd complince with progrms Evlute options with ctionble dt Robust cpture of pertinent demogrphic nd clinicl dt Evidence cquisition (cpture, nlysis, nd dissemintion of ctionble dt) Comprtive effectiveness reserch Ptients nd helth cre tem Stremline workflows (trnsform work processes) Support innovtion Ptients cost-effective self-cre Personlized cre decisions (ptients nd cre tem) Weigh different tretment Vlue-bsed decisions Policy nlysis Populte registries, dt repositories Should be utomted Should be utomted Should be utomted Should be utomted SOURCE: Ommy et l., Cre-Centered Clinicl Documenttion in the Digitl Environment: Solutions to Allevite Burnout, Ntionl Acdemy of Medicine. NOTE: [] Principl elements tht should be cptured by the clinicin during the ptient encounter nd recorded in clinicl documenttion. Pge 6 Published Jnury 29, 2018

7 Cre-Centered Clinicl Documenttion in the Digitl Environment would sve clinicins time nd prevent importnt informtion from flling through the crcks. Addressing Copy-Pste Documenttion Tools to help recognize the originl source of text pssges would help the clinicin reder ssess the credibility nd vercity of the text, s well s know which findings re new or chnged. Microsoft s Trck Chnges is n exmple of common editing tool tht helps the reder understnd the provennce of text pssge. Administrtive chnges, such s documenttion ssistnce nd empowered temwork tht direct dt entry tsks wy from clinicins, will reduce the pressure to copy nd pste or copy-forwrd. Copy nd pste cn be helpful nd time sving, but it must be used judiciously. Orgniztions hve identified prctices to promote sfe use of copy nd pste [41]. In ddition, regultory chnges tht relieve clinicins of the need to document low-vlue text e.g., ech element of norml physicl exm, complete review of systems, test results tht re lredy present elsewhere in the record, nd so on will reduce the need for copy nd pste. Trnsitioning to Pyment Reform One of the drivers leding to excessive nd duplictive text tht is so prevlent in tody s clinicl documenttion is the need to comply with billing rules. Pymentdriven documenttion criteri re rtifcts of the feefor-service environment tht hs dominted Americn medicine for decdes. As the United Sttes moves from fee-for-trnsctions to vlue-bsed purchsing, policy mkers should reexmine the need for documenttion tht serves billing needs nd replce it with documenttion tht serves cre. Ultimtely, returning to the origins of clinicl documenttion to communicte nd fcilitte cre would simplify documenttion, reduce the effort dedicted to producing it, nd encourge documenttion of only those fetures tht re most slient nd necessry to continuing cre. Applying User-Centered Design Principles As helth cre prctitioners trnsition from hndwritten documents in pper medicl records to electroniclly cptured structured nd unstructured documenttion, the helth cre enterprise should tke the opportunity to fundmentlly reexmine the methods used to enter nd retrieve essentil cre informtion. Insted of computerizing the pper-bsed methods of entering nd retrieving informtion, design-thinking methods should be employed to elucidte n efficient method for cpturing informtion nd n efficient nd effective wy of retrieving the informtion needed to support effective decision mking. The trnsition from pper-bsed record keeping to computer-bsed informtion mngement presents gret opportunity to fundmentlly relook t the most effective wy of cpturing nd using rich informtion bout n individul to mke the best possible decisions bout helth. A gol of this effort should be to improve trgeting of lerts nd reduce disruption in clinicin workflow. In ddition, the inclusion of socil nd behviorl dt tht helps drive ptient-focused tretment recommendtions nd the incorportion of ptient gols would be beneficil. Stndrds for utomted dt integrtion from medicl monitoring devices nd other IT systems will lso decrese clinicin burden of mnul dt entry [42]. A truly dvnced EHR system should provide ptient-specific outcome nd experience comprisons bsed on the treted popultion within the prctice [43]. Mchine-lerning pproches could dd to existing CDSS nd generte ccurte differentil dignoses nd determine high-vlue evlution pproches [44]. Mchine-lerning tools will likely ssist in error detection nd could improve dignostic ccurcy. Importntly, efforts to improve helth IT systems must ddress usbility or the effectiveness, efficiency nd stisfction with which specific users cn chieve specific set of tsks in prticulr environment [45]. A schem of the future stte is presented in Figure 2. Recommendtions To sy the evolution of clinicl documenttion in the digitl environment hs become merely source of disstisfction for clinicins grossly underestimtes its effect on burnout. Clinicins re clling for significnt redesign of clinicl documenttion to restore utonomy nd purpose to this spect of work, eliminte the perceived lrge number of ctions tht do not dd vlue, nd return time to clinicins for essentil cre ctivities. We recognize tht the primry drivers for current cpbilities in EHRs include regultory requirements, nd documenttion to support coding nd billing. As noted in this pper, however, the needs of clinicins nd ptients should be emphsized more directly nd better incorported s the primry drivers. Clinicins spend NAM.edu/Perspectives Pge 7

8 much of their time focused on documenttion nd relted coding issues. This use of highly specilized clinicl knowledge seems to be misppliction of resources. Menwhile, the ptients hve been left in their exm rooms or hospitl beds wondering if ll the ctivity going on is helping to ddress their needs. It is essentil tht clinicl documenttion be dequtely detiled so tht ptients dignoses nd cre cn be understood by clinicl collegues nd contribute constructively to tem-bsed cre. With the current system, we hve creted records tht re dense, where the relevnt informtion is chllenging to find, nd gps in the consistency of wht is documented re pprent. Clinicins hve lerned to simply jump through the hoops of dequte documenttion for reimbursement. Physicins re copying nd psting previous notes, chnging few detils, nd potentilly contributing to the incresing volume of unnecessry nd irrelevnt dt. Recognizing tht time is limited resource for ll clinicins, only essentil primry dt entry should be required of clinicins to support the cre of ptient. The cre tem needs to control wht documenttion demnds their ttention with optiml cpbility to cpture informtion t the point of cre. Secondry uses, such s billing, should be stisfied through mchine-cptured dt, which might be ddressed in EHR certifiction criteri. The technology lso needs to be enhnced to ddress the tension between structured versus unstructured documenttion. Given the time tht clinicins spend with inbox mngement, orgniztions should ensure tht messges indicte cler ction trgeted to specific udiences. Hving medicl ssistnts or other support personnel support documenttion (e.g., inbox mngement nd entering ptient dt into the EHR) improves clinicin stisfction nd reduces burnout [46]. However, the potentil for unintended consequences in dt ccurcy should be considered nd further evluted. Additionlly, providing time in workflows during the workdy to complete EHR documenttion tsks enhnces clinicin stisfction. Although not ddressing the underlying documenttion chllenges, scribes or tem-support mechnisms for documenttion enhnce physicin stisfction, increse time with ptients, nd dvnce chrting efficiency [47]. CQI CLEARINGHOUSE REGULATORS CLINICAL DOCUMENTATION * HOSPITAL OR CLINIC + PAYOR * AUTOMATED INPUT ACTIVE INPUT SEE TABLE 1 Figure 2 The Future Stte of Len, Stremlined, User-Designed System SOURCE: Ommy et l., Cre-Centered Clinicl Documenttion in the Digitl Environment: Solutions to Allevite Burnout, Ntionl Acdemy of Medicine. Pge 8 Published Jnury 29, 2018

9 Cre-Centered Clinicl Documenttion in the Digitl Environment Box 1 Recommendtions Clinicins should be responsible only for essentil primry dt entry tht is required to support the cre of ptient. EHR developers should increse the development of cpbilities tht llow clinicins to understnd the previous medicl, helth, nd socil history of the ptient. CMS should deemphsize documenttion requirements s condition of pyment for helth cre services. CMS should clrify tht elements of the HPI drfted by n ssistnt, nd confirmed with the ptient by the provider, should count for reimbursement. An uthorittive body, such s the NAM, should initite study focused on redesigning clinicl documenttion suited to the modern digitl ge, with primry focus on informing clinicl mngement nd improving ptient outcomes nd helth. Tble 1 Workforce Trining Pthwys, Competencies, nd Numbers by Discipline SOURCE: Ommy et l., Cre-Centered Clinicl Documenttion in the Digitl Environment: Solutions to Allevite Burnout, Ntionl Acdemy of Medicine. As the country trnsitions from py-for-trnsctions to py-for-vlue, the focus of documenttion should return to tht which supports high-qulity cre delivery nd tem communiction. The originl 1995 nd 1997 guidelines were developed to ensure tht feefor-service reimbursement ws justified. It would lso be beneficil for CMS to deemphsize documenttion requirements s condition of pyment for helth cre services. Deemphsizing (nd phsing out over time) the grnulr documenttion requirements would not only decrese the dministrtive work tht burdens clinicins, but lso improve the qulity nd meningfulness of the clinicl documents. CMS should clrify tht elements of the HPI drfted by n ssistnt (MA or nurse) during rooming, nd subsequently confirmed with the ptient by the provider, s indicted by the provider in the medicl record, should count for reimbursement. Focus on further development of helth informtics cpbility tht llows clinicins to view nd understnd the previous medicl, helth, nd socil history of the ptient, including detil regrding dignostic, surgicl, procedure, nd cre pln informtion, will improve current EHR workflow. Idelly, richer imging, video, nd other sources of informtion will be included. In this system, medicl history will be informed nd built on the input of vrious treting nd consulting clinicins with input nd review by the ptient. As best prctice, clinicins should be engged in development, testing, optimiztion, nd evlution of new EHR fetures such s clinicl decision support, order sets, nd templtes. EHR trining is often provided in limited number of sessions s n onbording component. However, dvnced longitudinl trining nd support of clinicl stff improves self-ssessment of competency [48,49]. The uthors recommend tht n uthorittive body, such s the Ntionl Acdemy of Medicine, inititive study focused on redesigning clinicl documenttion suited to the modern digitl ge with primry focus on informing clinicl mngement nd improving ptient outcomes nd helth. The study should focus on the needs of clinicins nd ptients in support of succinct documenttion nd use of informtics tools, which cn fcilitte nd stremline workflow. See Box 1. Conclusion As result of new nd emerging technology nd chnging consumer expecttions, helth cre will inevitbly trnsition to more person- nd fmily-centric helth system requiring the interoperbility of brod rry of helth solutions from trditionl resources, including clinicins nd hospitls, to the internet of things. As we enter n er of telehelth nd digitl pplictions, we re just beginning to understnd the effect of new technologies, such s mchine lerning nd blockchin solutions, on extending the vlue of helth cre nd better ligning it with the socil, genetic, environmentl, nd behviorl determinnts of helth [50]. Simultneously, pyment reform efforts re underwy to support this chnge with new models of vlue-bsed pyment tht rewrd improved personlized helth outcomes. As we study opportunities to ddress the existing chllenges of clinicl documenttion, we must do so with the understnding tht helth cre is t n inflection point nd will undergo unprecedented NAM.edu/Perspectives Pge 9

10 Tble 1 Workforce Trining Pthwys, Competencies, nd Numbers by Discipline chnge in the wy cre is delivered nd pid for in the coming yers. Florence Nightingle ws prophetic in her 1863 critique of hospitl documenttion tht described her difficulty in seeking informtion on ptient cre nd hospitl conditions, climing, I hve pplied everywhere for informtion, but in scrcely n instnce hve I been ble to find hospitl records fit for ny purpose of comprison [51]. Physicins 100 yers go brought forth the ide of dequte documenttion to estblish their professionl responsibilities to their ptients nd to themselves. In the present environment, clinicins hve lost control of this responsibility, nd it is hving deleterious effects on the uthenticity of their work, their sense of utonomy, ptient outcomes, nd the functions of the clinicl environment. It is time to rethink the ptient record nd how it cn best be used to improve person-centered cre. References 1. Shnfelt, T. D., nd J. H. Noseworthy Executive ledership nd physicin well-being: Nine orgniztionl strtegies to promote enggement nd reduce burnout. Myo Clinic Proceedings 92(1): Shnfelt, T. D., L. N. Dyrbye, C. Sinsky, O. Hsn, D. Stele, J. Slon, nd C. P. West Reltionship between clericl burden nd chrcteristics of the electronic environment with physicin burnout nd professionl stisfction. Myo Clinic Proceedings 91(7): Kelley, T. F., D. H. Brndon, nd S. L. Docherty Electronic nursing documenttion s strtegy to improve qulity of ptient cre. Journl of Nursing Scholrship 43(2): Kzmi, Z Effects of exm room EHR use on doctor-ptient communiction: A systemtic literture review. Informtics in Primry Cre 21(1): Lvin, M. A., E. Hrper, nd N. Brr Helth informtion technology, ptient sfety, nd professionl nursing cre documenttion in cute cre settings. Online Journl of Issues in Nursing 20(2):6. 6. Dyrbye, L. N., T. D. Shnfelt, C. A. Sinsky, P. F. Ciprino, J. Bhtt, A. Ommy, C. P. West, nd D. Meyers Burnout mong helth cre professionls: A cll to explore nd ddress this underrecognized thret to sfe, high-qulity cre. NAM Perspectives. Discussion Pper, Ntionl Acdemy of Medicine, Wshington, DC. Helth-Cre-Professionls. 7. Junger, S Tribe: On homecoming nd belonging. New York: HrperCollins. 8. Kssell, L Csebooks in erly modern Englnd: Medicine, strology, nd written records. Bulletin of the History of Medicine 88(4): Goroll, A. H Emerging from EHR purgtory: Moving from process to outcomes. New Englnd Journl of Medicine 376(21): Cheng, C. H., M. K. Goldstein, E. Geller, R. E. Levitt The effects of CPOE on ICU workflow: An observtionl study. Americn Medicl Informtics Assocition Annul Symposium Proceedings, Mrtin, S. A., nd C. A. Sinsky The mp is not the territory: Medicl records nd 21st century prctice. Lncet 388(10055): Centers for Medicre nd Medicid Services Evlution nd mngement services. cms.gov/outrech-nd-eduction/medicre-lerning-network-mln/mlnproducts/downlods/evlmgmt-serv-guide-icn pdf 13. Berenson, R. A., P. Bsch, nd A. Sussex Revisiting E&M visit guidelines missing piece of pyment reform. New Englnd Journl of Medicine 364(20): Adler-Milstein, J., nd A. K. Jh HITECH Act drove lrge gins in hospitl electronic helth record doption. Helth Affirs (Millwood) 36(8): Wshington, V., K. DeSlvo, F. Mostshri, nd D. Blumenthl The HITECH er nd the pth forwrd. New Englnd Journl of Medicine 377(10): Pge, N., M. T. Bysri, nd J. I. Westbrook A systemtic review of the effectiveness of interruptive mediction prescribing lerts in hospitl CPOE systems to chnge prescriber behvior nd improve ptient sfety. Interntionl Journl of Medicl Informtics 105: Poissnt, L., J. Pereir, R. Tmblyn, nd Y. Kwsumi The impct of electronic helth records on time efficiency of physicins nd nurses: A systemtic review. Journl of the Americn Medicl Informtics Assocition 505: Ali, S. M., R. Giordno, S. Lkhni, nd D. M. Wlker A review of rndomized controlled trils of medicl record powered clinicl decision support system to improve qulity of dibetes cre. Interntionl Journl of Medicl informtics 87: Pge 10 Published Jnury 29, 2018

11 Cre-Centered Clinicl Documenttion in the Digitl Environment 19. Slight, S. P., E. S. Berner, W. Glnter, S. Huff, B. L. Lmbert, C. Lnnon, C. U. Lehmnn, B. J. Mc- Court, M. McNmr, N. Menchemi, T. H. Pyne, S. A. Spooner, G. D. Schiff, T. Y. Wng, A. Akincigil, S. Crystl, S. P. Fortmnn, nd D. W. Btes Meningful use of electronic helth records: Experiences from the field nd future opportunities. JMIR Medicl Informtics 3(3):e Wolfstdt, J. I., J. H. Gurwitz, T. S. Field, M. Lee, S. Klkr, W. Wu, nd P. A. Rochon The effect of computerized physicin order entry with clinicl decision support on the rtes of dverse drug events: A systemtic review. Journl of Generl Internl Medicine 23(4): Strom, B. L., J. P. Metly, A. Cohen, B. Abluck, A. R. Loclio, S. E. Kimmel, nd B. L. Storm The role of CPOE in fcilitting mediction errors. Archives of Internl Medicine 170; Ti-Sele, M., C. W. Olson, J. Li, A. S. Chn, C. Morikw, M. Durbin, W. Wng, nd H. S. Luft Electronic helth record logs indicte tht physicins split time evenly between seeing ptients nd desktop medicine. Helth Affirs (Millwood) 36(4): Christino, M. A., A. P. Mtson, S. A. Fischer, S. E. Reinert, C. W. Digiovnni, nd P. D. Fdle Pperwork versus ptient cre: ntionwide survey of residents perceptions of clinicl documenttion requirements nd ptient cre. Journl of Grdute Medicl Eduction 5(4): Sinsky, C., L. Collign, L. Li, M. Prgomet, S. Reynolds, L. Goeders, J. Westbrook, M. Tutty, nd G. Blike Alloction of physicin time in mbultory prctice: A time nd motion study in 4 specilties. Annls of Internl Medicine 165(11): Vn der Sijs, H., J. Arts, A. Vulto,nd M. Berg Overriding of drug sfety lerts in computerized physicin order entry. Journl of the Americn Medicl Informtics Assocition 13(2): Nnji, K. C., S. P. Slight, D. L. Seger, I. Cho, J. M. Fiskio, L. M. Redden, L. A. Volk, nd D. W. Btes Overrides of mediction-relted clinicl decision support lerts in outptients. Journl of the Americn Medicl Informtics Assocition 21(3): Murphy, D. R., A. N. Meyer, E. Russo, D. F. Sittig, L. Wei, nd H. Singh The burden of inbox notifictions in commercil electronic helth records. JAMA Internl Medicine 176(4): Showell, C Brriers to the use of personl helth records by ptients: structured review. PeerJ 5:e Adler-Milstein, J., S. C. Lin, nd A. K. Jh The number of helth informtion exchnge efforts is declining, leving the vibility of brod clinicl dt exchnge uncertin. Helth Affirs (Millwood) 35(7): Everson, J The implictions nd impct of 3 pproches to helth informtion exchnge: community, enterprise, nd vendor-medited helth informtion exchnge. Lerning Helth Systems 1(2):1-9. e Adler-Milstein. J., nd E. Pfeifer Informtion blocking: Is it occurring nd wht policy strtegies cn ddress it? Milbnk Qurterly 95(1): Ntionl Qulity Forum Mesure frmework to ssess ntionwide progress relted to interoperble helth informtion exchnge to support the ntionl qulity strtegy. Wshington, DC. Ntionl Qulity Forum. 33. Ntionl Acdemy of Medicine The computer-bsed ptient record: An essentil technology for helth cre. Ntionl Acdemy Press: Wshington, DC. 34. Friedberg, M. W, P. G. Chen, K. R. Vn Busum, F. Aunon, C. Phm, J. Cloyers, S. Mttke, et l Fctors ffecting physicin professionl stisfction nd their implictions for ptient cre, helth systems, nd helth policy. RAND Helth Qurterly 3(4): Wng, M. D., R. Khnn, nd N. Njfi Chrcterizing the source of text in electronic helth record progress notes. JAMA Internl Medicine 177(8): Tsou, A. Y., C. U. Lehmnn, J. Michel, R. Solomon, L. Possnz, nd T. Gndhi Sfe prctices for copy nd pste in the EHR. Systemtic review, recommendtions, nd novel model for helth IT collbortion. Applied Clinicl Informtics 8(1): Siegler, E. L The evolving medicl record. Annls of Internl Medicine 153(10): NAM.edu/Perspectives Pge 11

12 38. Suer, B. C., B. E. Jones, G. Globe, J. Leng, C. C. Lu, T. He, C. C. Teng, P. Sullivn, nd Q. Zeng Performnce of nturl lnguge processing (NLP) tool to extrct pulmonry function test (PFT) reports from structured nd semistructured Vetern Affirs (VA) dt. The Journl for Electronic Helth Dt nd Methods (Wshington, DC) 4(1):1217. doi: / ecollection Liu, L., N. H. Shorstein, L. B. Amsden, nd L. J. Herrinton Nturl lnguge processing to scertin two key vribles from opertive reports in ophthlmology. Phrmcoepidemiol Drug Sfety 26(4): doi: /pds Epub 2017 Jn Kufmn, D. R., B. Sheehn, P. Stetson, A. R. Bhtt, A. Field, C. Ptel, nd J. M. Misel Nturl lnguge processing-enbled nd conventionl dt cpture methods for input to electronic helth records: A comprtive usbility study. JMIR Medicl Informtics 4(4):e Prtnership for Helth IT Ptient Sfety Helth IT sfe prctices: toolkit for the sfe se of copy nd pste. Toolkit/Toolkit_CopyPste_finl.pdf 42. Wever, C., nd A. O Brien Trnsforming clinicl documenttion in EHRs for 2020: Recommendtions from University of Minnesot s big dt conference working group. Studies in Helth Technology & Informtics 225: Zulmn, D. M., N. H. Shh, nd A. Verghese Evolutionry pressures on the electronic helth record: Cring for complexity. Journl of the Americn Medicl Assocition 316(9): Szlosek, D. A., nd J. Ferrett Using mchine lerning nd nturl lnguge processing lgorithms to utomte the evlution of clinicl decision support in electronic medicl record systems. The Journl for Electronic Helth Dt nd Methods (Wshington, DC) 4(3): Schoeffel, R The concept of product usbility. Interntionl Orgniztion for Stndrdiztion Bulletin 34: Linzer, M., S. Poplu, E. Grossmn, A. Vrkey, S. Yle, E. Willims, L. Hicks, R. L. Brown, J. Wllock, D. Kohnhorst, nd M. Brbouche A cluster rndomized tril of interventions to improve work conditions nd clinicin burnout in primry cre: Results from the Helthy Work Plce (HWP) study. Journl of Generl Internl Medicine 30(8): Gidwni, R., C. Nguyen, A. Kofoed, C. Crrgee, T. Rydel, I. Nellign, A. Sttler, M. Mhoney, nd S. Lin Impct of scribes on physicin stisfction, ptient stisfction, nd chrting efficiency: A rndomized controlled tril. Annls of Fmily Medicine 15(5): Abrhmson, K., J. G. Anderson, E. M. Borycki, A. W. Kushniruk, S. Mlovec, A. Espejo, nd M. Anderson The impct of university provided nurse electronic medicl record trining on helth cre orgniztions: An explortory simultion pproch. Studies in Helth Technology nd Informtics 208: Kim, J. G., H. P. Rodriguez, K. A. Estlin, nd C. G. Morris Impct of longitudinl electronic helth record trining for residents prepring for prctice in ptient-centered medicl homes. The Permnente Journl, Yli-Huumo, J., D. Ko, S. Choi, S. Prk, nd K. Smolnder Where is current reserch on blockchin technology? A systemtic review. PLoS One 11(10):e Nightingle, F Notes on Hospitls, 3rd ed. London: Longmn, Green, Longmn, Roberts, nd Green. p Suggested Cittion Ommy, A. K., P. F. Ciprino, D. B. Hoyt, K. A. Horvth, P. Tng, H. L. Pz, M. S. DeFrncesco, S. T. Hingle, S. Butler, nd C. A. Sinsky Cre-dentered clinicl documenttion in the digitl environment: Solutions to llevite burnout. NAM Perspectives. Discussion Pper, Ntionl Acdemy of Medicine, Wshington, DC. Author Informtion Alexnder K. Ommy, DSc, MA, is the senior director of Clinicl Reserch nd Policy t the Assocition of Americn Medicl Colleges. Pmel F. Ciprino, PhD, RN, NEA-BC, FAAN, is the president of the Americn Nurses Assocition. Dvid B. Hoyt, MD, FACS, is the executive director of the Americn College of Surgeons. Keith A Horvth, MD, is the senior director of Clinicin Trnsformtion t the Assocition of Americn Medicl Colleges. Pul Tng, MD, MS, is the vice president nd chief helth trnsformtion officer t IBM Wtson Helth. Hrold L. Pz, MD, MS, is the executive vice president nd chief medicl officer t Aetn. Mrk S. Pge 12 Published Jnury 29, 2018

13 Cre-Centered Clinicl Documenttion in the Digitl Environment DeFrncesco, MD, MBA, FACOG, is pst president of the Americn College of Obstetricins nd Gynecologists. Susn T. Hingle, MD, is chir of the Bord of Governors t the Americn College of Physicins. Sm Butler, MD, is the chief medicl officer t Epic. Christine A. Sinsky, MD, is the vice president of the Americn Medicl Assocition. Acknowledgments The uthors would like to cknowledge Colin P. West, MD, PhD, Myo Clinic nd Ptrici Sengstck, DNP, RN-BC, CPHIMS, Bon Secours Helth System for their vluble contributions to this pper. The uthors would lso like to thnk Chrlee Alexnder, progrm officer; Mrin Zindel, reserch ssistnt; nd Imni Rickerby, progrm ssistnt t the Ntionl Acdemies of Sciences, Engineering, nd Medicine for the vluble support they provided for this pper. Conflict-of-Interest Disclosures None disclosed. Disclimer The views expressed in this pper re those of the uthors nd not necessrily of the uthors orgniztions, the Ntionl Acdemy of Medicine (NAM), or the Ntionl Acdemies of Sciences, Engineering, nd Medicine (the Ntionl Acdemies). The pper is intended to help inform nd stimulte discussion. It is not report of the NAM or the Ntionl Acdemies. Copyright by the Ntionl Acdemy of Sciences. All rights reserved. NAM.edu/Perspectives Pge 13