AMIA board of directors response to Simborg perspective.

Systematic clinical documentation, the recording of observations and impressions resulting from healthcare, began over 200 years ago.1 The purpose of clinical documentation has varied over the years and currently supports communication among the care team members, teaching, research, and medical billing.1 Computer-based documentation (CBD) has been in place at leading informatics institutions for decades, and its prevalence will increase due to the Meaningful Use program. CBD is associated with numerous positive factors, including that it can be accessible remotely, can be more easily used for research and operational management, can better support team-based care, and can better support healthcare providers’ decision making.2 However, CBD use carries with it some important challenges. For example, CBD can be more time consuming than paper-based or dictation-based clinical documentation. Also, CBD often imports electronic data from other parts of the patient's chart to increase completeness, but can lead to ‘note bloat’ and destroy the narrative that concisely describes the patient's condition. Excessive structure, for example, as may be imposed by templates, can inhibit a healthcare provider's expressivity.2 Simborg3 notes that another complexity of CBD is that it can be used to promote fraudulent clinical documentation. He notes that certain documentation-related features in electronic health record (EHR) systems can be used to perpetuate fraud, and in some cases are intended ‘solely’ to do so. Common examples include ‘cloning’ (copy/paste) and decision support that can be used to help healthcare providers ‘up-code’ their notes in particular situations. Simborg suggests that the Office of the National Coordinator (ONC) for Health Information Technology exercise its EHR certification authority to prohibit CBD features that can contribute to fraud, and consider decertifying products that support such capabilities. He also suggests that ONC require certified EHRs to contain additional metadata to support improved auditing of clinical documentation practices. Simborg acknowledges the limitations in the current state of knowledge. Fraud existed prior to the use of EHRs, and it is not known to what extent EHRs increase the magnitude of the problem. A report from the Office of the Inspector General in May, 2012,4 noted an increase in the use of higher level billing codes in emergency departments from 2001 to 2010. A follow-up analysis by the New York Times in September, 2012,5 showed that since 2006, hospitals that received Meaningful Use payments had a faster rise in the use of these highest level billing codes than those that did not. The report does not specify if confounders were present or were adequately controlled for.6 For example, it is not clear whether the billing reflected more complete and accurate documentation of care, or if these technically advanced organizations had other programs in place that provided more thorough care. It is also not clear to what extent these findings from emergency settings may relate to ambulatory and other settings of care. There would be challenges to implementing Simborg's recommendations. For example, it can be difficult to determine when a particular software feature is intended ‘solely’ for one purpose or another. EHR systems are software tools, and how they are used often is determined by the healthcare provider. As a result, it is unclear whether the software or its use is the best focus for fraud mitigation activities. Further, there are situations in which some of the named functions can actually increase safety. For example, copy/paste may improve clinical documentation accuracy in the setting of a patient with complex breast cancer who has a detailed set of risk factors, genetic test results, and past treatments documented in her history of present illness (HPI). Allowing healthcare providers to use the existing HPI as the starting point for future clinical documentation and make adjustments from there would have a lower chance of errors of omission than requiring the re-entry of all the historical data. This is especially true when there has been an extended time interval between visits. In addition, there are emerging tools that can measure the amount of redundancy in clinical notes,7 and provider organizations may wish to consider these. Also, Simborg suggests that ONC should standardize metadata elements to improve fraud detection. The requirements for such data elements may not yet be clear so setting standards may be premature, although increasing use of CBD may help identify what such elements should be. Other than fraud detection, there are significant hurdles to making CBD as effective as possible. A recent AMIA policy conference noted that the primary purpose of CBD should be to support clinical processes, and that payment-focused documentation should be secondary.2 From an informatics perspective, the information models that support CBD need to be improved. Certain data elements change slowly over time, such as past medical history, social history, and family history. Certain physical examination findings need to be updated with each clinical encounter. Still others, such as the HPI, may change slightly between encounters. CBD needs to allow these data elements, which have different characteristics, to be managed coherently. Research focused on improving CBD is sorely needed.2 For CBD to fulfill its potential, healthcare providers need a suite of electronic documentation support tools that allow views into other parts of the EHR, and the ability to reference them as necessary. The need for such support is evident from a study from the Veterans Administration (VA) that noted the extensive use of copy/paste.8 At the VA, there is no financial incentive to use copy/paste, and this function was likely used primarily to address some of the inefficiencies introduced by CBD. Other CBD-related research areas include increasing the ease of data entry, improving the readability of the output documents, and determining the relationship between the quality of CBD and the quality of care. Additional requirements for the output of CBD will emerge as patients increasingly have access to clinicians’ notes. In summary, while fraudulent documentation is a serious concern, more needs to be done to document the extent and root causes of the problem before regulatory changes are put into place. In addition, and more importantly, further research and innovation is needed to improve CBD and EHR system design so that the primary goal of improved patient care can be realized.