The American College of Physicians (ACP) offers several recommendations for the more effective use of electronic health records (EHRs) in a new policy position paper published in the Annals of Internal Medicine.
These recommendations are meant to help healthcare providers, vendors, government agencies and payers to improve clinical documentation and the sharing of information through EHRs.
The authors contend that the definitions of both EHRs and clinical documentation have evolved over the years and now include a broad range of functions and information that must be utilized to better deliver high quality patient care.
Among the recommendations are that EHRs should display historical information in rich context; support critical thinking; enable efficient and effective documentation; and support secure sharing of information among providers, patients, family members and caregivers.
But the authors also say that physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of clincial notes and other narrative entries, such as comments on activities of daily living.
In addressing its recommendations to EHR developers, the ACP advises:
- Optimizing EHR systems to facilitate longitudinal care delivery and care that involves teams of clinicians and families
- Clinical documentation must support clinicians' cognitive processes during the documentation process
- EHRs must support "write once, reuse many times" and embed tags to identify the original source of information when used subsequent to its first creation.
- Wherever possible, EHR systems should not require users to check a box or otherwise indicate that an observation has been made or an action has been taken if the data documented in the patient record already substantiate the actions, and
- EHR systems must facilitate the integration of patient-generated data and must maintain the identity of the source.