As a follow-up to last week’s article The History of EMRs: Opportunities to Improve Patient Safety, we explore the philosophy around providing EHR documentation templates that include specialty-specific, chief complaint clinical content. Doing so provokes a few big-picture questions about healthcare information technology and the appropriate strategy for designing clinical applications that providers work with daily.
- How should EMRs be built and how should they be organized for the clinician?
- What is the optimal documentation environment?
- Should practitioners simply open up a white space and type or dictate?
- Should they utilize canned text or macros that completely populate a medical record with a click or a phrase?
- Can they rely on current memory and knowledge base without visual guidance?
These questions depend heavily on the specialty. For example, little clinical content would be required for orthopedic surgeons who focus only on hip replacements. But for primary care specialties, pediatrics, emergency medicine and other specialties that basically “take all comers” and see a broad variety of complaints, a blank white space for typing or dictation is not optimal. Having access to high-quality complaint-focused content is critical to helping the providers formulate their medical decision-making process around key elements that were obtained in the History and Physical Exam.
What exactly is “content”? Content consists of the clinical queries and data points that make up a patient medical record. At the highest level, it refers to the patient history of present illness (HPI), past medical history, review of systems, physical exam and medical decision-making. Other important data points include patient age, sex and vital signs. Within the history of present illness would be queries such as chief complaint, timing of onset, and radiation of pain in a patient presenting with chest discomfort. Within each of those would be individual data points asking questions to determine if, for example, the timing of onset was sudden or abrupt like an aortic dissection or if it was crescendo like a myocardial infarction. Those individual data points create a data set that moves the practitioner’s judgment toward one or more diagnoses and away from others.
The ultimate goal here is to provide content that is relevant to the patient experience and that supports and perhaps guides the practitioner’s decision-making. If a 25-year-old male presents to the ED with pain that started at the belly button and is now in the right lower quadrant and it hurts a lot when you push on it, the practitioner does not need any content. That is not much of a diagnostic challenge. He simply needs to call a surgeon and get the patient to the OR to have his appendix removed. Documentation can follow.
However, clinical life is rarely so straightforward, and patients usually don’t present to the office or ED with a diagnosis on a sticky note; many require sophisticated decision-making. In specialties where 50 to 100 different chief complaints may present, quality content can support and guide decision-making.
That said, EMR content does serve several masters. If practitioners or hospitals are to be reimbursed for care provided, then billing and coding formulas must be met; therefore, content supports billing and coding. Content supports hospital and physician quality metrics associated with such regulations as Value-Based Purchasing and MACRA. Without content reminders, it is difficult or impossible to demonstrate compliance with metrics that are tied to reimbursement.
But the patient is the highest priority, and complex decision-making often requires more computing power than most clinicians have available in current memory.
A couple of examples will serve to underscore the importance of quality content and make the case for complaint-associated modules or clinical templates.
When determining the cause of chest pain, particularly in older adults, one important query is whether there has been movement or migration of pain. This doesn’t mean the typical crushing substernal chest pain that “radiates” down the left arm; this means actual movement of pain. From a recent case review, a 43-year-old male had chest pain at home when he called the ambulance. When he got to the ED, he had abdominal pain. The pain had moved. That can only be one thing – his aorta was dissecting. It started near the heart (chest pain) and dissected down past the kidneys (abdominal pain). That one key practitioner query would make the diagnosis. However, the practitioner never inquired as to whether that pain moved; he focused on the gallbladder while the patient’s aorta continued to dissect, and the patient died.
In a white space or dictation environment, that question will not be asked. That critical “content” is not in most practitioner’s thought process without some kind of visual guide or reminder. It is simply the human condition; it is impossible to learn and remember all that is required for high-quality decision-making in a stressful environment. In an analysis of a number of boutique and large EHR vendor “chest pain” templates, the question about movement of pain was not present at all. But it is a critically important data element for EMR content — chest pain moving to the abdomen is an aortic dissection. That one data point drives the diagnosis. And aortic dissection is a common failure-to-diagnose entity in emergency medicine!
Consider a 20-day-old neonate presenting with a change in behavior. Once again, there are certain key data elements or content that help reveal the diagnosis. One of the most important in this fact pattern is whether there was exposure to Group B Strep or herpes in the maternal birth environment. Practitioners working in a white space or dictation setting or those using universal macros or canned text will typically not address that issue. Herpes encephalitis will kill the child if not recognized and treated immediately. If the Group B Strep and herpes issues are not in current memory or part of the practitioner’s knowledge base, the question will not be asked and the diagnosis will be missed or delayed; the question should be asked 100% of the time. There is no room for variability. A visual guide here is critical; content related to this issue should appear in some format inside the EMR. There should be complete clinical practice pattern alignment around this issue.
The takeaway here is that in the “take all comers” clinical environment, some kind of structured EMR format is strongly recommended. Key clinical queries or content that help drive toward the correct diagnosis, support the billing and coding requirements, and assist in compliance with key reimbursement-based metrics must be provided within the EHR environment.