Something really interesting is happening these days around physician documentation. For years now, as patient care organizations have implemented electronic health records (EHRs), the shift from paper to electronic documentation has led to some unfortunate unintended consequences. Chief of these has been the phenomenon of “note bloat”—the electronic agglutination of physician notes and other data, clogging the EHR with so much content, often poorly organized, leading to physician frustration and even potentially, medical errors.
Though some preliminary physician documentation reform had been emerging in the past few years, the OpenNotes Movement and broader consumerism are flipping the script these days on physician documentation. With patients now being handed an ever-larger share of their bills via high-deductible health plans from their employers, and with expectations rising, as consumers in every other area of services can easily access and even control their data and information, a shift is taking place that is pushing the leaders of patient care organizations to conclude that it makes sense to bring patient further into engagement with their doctors by letting them see their doctors’ progress notes and other data and information—which, after all, is their information anyway, it is often pointed out.
But allowing patients to see physician notes means that those notes must be presentable, readable, and understandable. Thus, the burning platform needed to reform physician documentation.
CMIOs of organizations moving forward in this area agree—this is a trend whose time has come. Indeed, “All of this represents a focus on transparency, and patients understanding better their health, and the treatments they’re being offered,” says Vivek Reddy, M.D., CMIO at the 20-plus-hospital UPMC (University of Pittsburgh Medical Center) health system. “So there’s this huge shift towards greater awareness, and also using documentation as a way to help patients co-manage their diseases—so that you understand your treatments and the rationale between them.”
Read Mark Hagland’s full article here!
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