EHR documentation challenges remain
Opportunities for improvement
The Accreditation Association for Ambulatory Health Care (AAAHC) in its Quality Roadmap 2016 also singled out issues with documentation, saying it’s an area that offers opportunities for improvement.
Cheryl Pistone, the AAAHC’s clinical director for ambulatory accreditation said the organization found that a physician’s EHR frequently didn’t have documentation from external providers nor did it always have enough information in particular circumstances. Namely, EHRs did not contain enough documentation on patients’ allergic reactions to medicine nor did they contain updated medication information. Additionally, EHRs do not always contain adequate details on small procedures, such as removing a small growth, done by physicians in their offices.
Pistone said EHRs should be configured to require physicians to add details about allergic reactions and then automatically populate that information in the multiple places within the medical record where it is needed.
EHRs should also be configured to enable doctors to easily enter information in narrative form. Then the EHR should use artificial intelligence (AI) and analytics to populate, parse and present data for physicians when and where they need it, Payne said.
Payne pointed out that leading EHR vendors as well as other software makers are developing and beginning to deploy more of these technologies, while technologies that support interoperability, such as the growing use of the Fast Healthcare Interoperability Resources (FHIR) standard, are speeding advancements on that front.
Improvements are long overdue, experts said.
“Documentation is a great example of where a problem exists today and where the pace of technology improvements is not as great as everyone hoped,” said Payne.