Background: Medical Documentation Now and Then. The transition from paper to digital medical records has occurred over the past few decades, with an acceleration fostered by HITECH passed in 2009. Eligible providers were granted incentive payments for adopting certified Electronic Health Record (EHR) systems. Through three stages of Meaningful Use, healthcare providers were expected to use EHRs to improve the quality of patient care. In the process, documentation expectations have changed, and many physicians report concerns about care delivered to individual patients and populations as well as patient safety. They believe that medical documentation has become captive to requirements that cloud the narrative necessary to support the delivery of care, especially of complex, chronic care of patients with multiple clinicians.
Background. The first JASON report sharply criticized legacy electronic health records’ (EHRs’) ability to share information. In follow-up, ONC held meetings  before setting a new strategic direction outlined in their recently released 5 year strategic plan that reset the timeline to achieve meaningful interoperability. “Data for Individual Health” was released in November and addresses the potential uses of health information – “to expand this vision, with a focus on the health of individuals and the development of a Learning Health System.” 
ACP Recommendations. In their recent position paper,  twelve policy recommendations are made covering clinical documentation and EHR design. In order to return to its original purpose, the position paper asks that the “primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication.”  In addition, they recommend that:
- Physicians should define standards for documentation, and information exchange should be facilitated by standards set by individual specialties.
- EHRs should facilitate seamless patient care that improves outcomes and support data analysis that enables value-based care.
- Collecting structured data should only be done when useful for care or important for quality improvement.
- Prior authorizations should not require unique data and format requirements.
- Patient engagement and care quality will be enhanced when patients are able to access their progress notes as well as the rest of their record.
- Research is needed to improve the processes involved in documenting care and facilitating technological advancements that allow better, more accurate record of observations.
- EHR development should be optimized for longitudinal team-based care.
- Cognitive processes during documentation should be supported in EHR design.
- When reusing data, embedded tags should be included to identify the original source
- Checkboxes to indicate something that has already been documented should be eliminated.
- Patient-generated data should be incorporated into their medical record and the source identity maintained.
Changing patient expectations. As patients experience more complex problems, they and their family caregivers have become more vocal in demanding better communication among their various clinicians and with their clinicians. EHR portals are now available where patients can access much of their data. The highly successful OpenNotes project is an example of how eager patients are to receive more of their medical information.  Complications can arise, however, when (as is often the case today) patients have multiple providers with whom they need to communicate. In addition, long term care providers – nursing homes or home health care agencies – may not have portals or other ways to digitally communicate with patients, family caregivers or the larger healthcare team. Some independent organizations, payers and providers themselves have begun to create these capabilities, but we’re just at the beginning of understanding how it will work and who will pay for it. Will it be part of providers’ bundled services to their patients? Will patients pay for services directly or through a third party? Will employers or insurers pay for it for their beneficiaries?
Another capability patients request is to allow them to contribute data to their medical record. Whether it is device data from weight scales and oxygen saturation monitors or hand-entered data such as demographics and basic health information to avoid clipboards at clinic visits, patients want the convenience of contributing information that can be sent directly to their clinicians and medical records. They also will want to bring family members and other advisors into the conversation so they can feel confident that they understand their conditions, the treatments offered and what will be involved in embarking on a plan of care. As treatments become more complicated and more likely to be delivered at home, patients need ways to access information when they need it to successfully implement prescribed care.
Coding requirements have changed medical documentation. The process of developing better billing codes for fee-for-service medical visits began before EHRs were implemented, but problems have been exacerbated by EHR system developers that have been “oriented toward providing documentation needed to satisfy auditors rather than developing important functions such as clinical decision support that would improve patient care.”  The coding process has become so complex that it has become the focus of patient encounter documentation. The ACP believes that optimal patient care and quality outcomes should be the focus of documentation as it was in the past.
In addition, coding for “e-measures” has not been easy, and in many instances requires additional information to be entered into structured fields. This activity is not likely to be a priority for clinicians, which means that inaccurate and incomplete quality measurement reports will be the result. Ways to more seamlessly measure quality need to be developed so that reports are accurate and providers can take advantage of the activities to improve care.
New capabilities enabled by technology. EHR design for optimizing function is in its infancy, and tools are available to help clinician informaticists experiment with design.  New, more flexible standards, such as FHIR®, as well as data transport approaches and cloud computing are now available that can make sharing, managing and analyzing data simpler. Several new initiatives are underway and promise opportunities to better meet patients’ and clinicians’ needs.
I believe that we have not spent enough time determining what is needed to optimally deliver care outside the hospital setting. In many ways, ambulatory EHRs are built assuming that (1) patients won’t/shouldn’t enter their own data; (2) patients are in communication with their clinicians much more than they actually are; and (3) data is easily aggregated by clinicians across organizations. If you compare patients’ needs when hospitalized to needs when not in the hospital, the difference is obvious. When hospitalized, patients have professionals monitoring their status and available to answer questions at all times. Physicians and other support professionals come to the patient, not the other way around, and they all utilize the same record. Expectations about how these systems would work in primary care and specialty clinics may have been overly optimistic, and we therefore need to rethink how goals can be reached. Henry Ford had to go through Models A through S before getting to the Model T. Perhaps we need more experimentation to achieve the promise of EHRs that support the tasks of clinicians, patients and families.
 Kuhn T, Basch P, Barr M, Yackel T. Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians. Ann Intern Med online-first version published January 13, 2015. Accessed at http://annals.org/article. aspx?articleid=2089368.
 Ibid., page 2.
 Delbanco T, Walker J, Darer J, et al. Open Notes: Doctors and Patients Signing On. Ann Intern Med 153(2):121-5 (2010). Accessed at http://annals.org/article.aspx?articleid=745909.
 Berenson RA, Basch P, Sussex A. Revisiting E&M Visit Guidelines—A Missing Piece of Payment Reform. N Engl J Med 364(20):1892-5 (2011). Accessed at http://www.nejm.org/doi/full/10.1056/NEJMp1102099.
 Carter J. An Informatics Exploratorium for EHR Design. EHR Science Blog (February 9, 2015). Accessed at http://ehrscience.com/2015/02/09/an-informatics-exploratorium-for-ehr-design/?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+Ehrsciencecom+%28EHR+Science%29.