Transition from paper to EHRs creates both opportunities and problems

Electronic health records (EHRs) have dramatically changed the way clinical documentation is used and the role it plays in health care. A recent report from the American Academy of Pediatrics (AAP) reviews some of the major changes that have been made in the transition from paper to EHRs, and how to manage these changes in an attempt to recommend best practices.

The report,¹ published in Pediatrics, is a result of the work of AAP’s Council on Clinical Information Technology. It reviews documentation models specific to pediatric practice, alternative documentation techniques that could improve efficiency, outlines best practices, and discusses how to best utilize shared documentation where both patients and providers contribute.

Historically, clinical documentation was a tool for the health care provider alone. New technologies, outpatient monitoring, patient-controlled devices, and EHRs with patient portals have changed all that. With all the new benefits these changes bring in terms of clinical care and access to data, there have also been a number of challenges.

One of these challenges is the sheer volume of data that is not available to both providers and patients. Additionally, with patients being able to input data, there is now a non-clinical element to the EHR. Technological advances in electronic documentation aimed at reducing workload—like copy and paste function or pre-programmed phrases—have helped clinicians save time, but have also had unintended consequences, namely bloated and lengthy notes that decrease the effectiveness of the electronic record.

The report outlines a number of factors that should be considered in pediatric electronic record keeping. The first is the focus on documentation styles. Data displays should focus on the needs of both patients and providers, in a way that provides clinicians the data they need without being confusing to patients and parents. Documentation also has to be flexible. Changes are made constantly to evidence-based practice and protocols. Updates to recommendations and how results are reviewed within medical charts should be visible to both patients and providers.

There is also a need to have a streamlined structure for data display, including a template of sorts for notes so that clinical information can easily be found. One recommendation for the report is to use the subjective, objective, assessment, and plan (SOAP) 2.0 note structure, which focuses on documentation that is succinct, original, accurate, and problem-based.

The enormous amount of data in EHRs is also causing a problem with managing information overload, according to the report.

“The concern is that the large volume of clinical information can lead to a clinical care provider overlooking important clinical information ,” the report notes. “Technological solutions are necessary to mitigate this problem and maintain clinical care efficiency and value, including integrating graphs, tabular data, knowledge management tools, mart search engines, links to Web-based resources and customized menus.”

A hierarchical display of data is key to manage information appropriately, highlight important metrics, and preventive information overload.

Care must also be taken to consider the additional stakeholders that review and use health records, the report notes, such as billing agents and regulators. Electronic health records may be to blame for increased use of higher level Current Procedural Terminology (CPT) codes, and clinicians must be aware of this issue and work to reduce irrelevant information in their documentation that could lead to more complex CPT codes than are warranted.

Clinicians also have to keep in mind that EHRs have also become a vital tool for others invested in a child’s care—school workers, counselors, parents, and more. Structured, and well-organized documentation that can be used for a wide variety of health-related activities is crucial.

The report gives an overview of the numerous benefits—and challenges—that have arisen from the transition of medical records from paper to electronic. Although there are a number of improvements that have been made, continued work s needed to used shared documentation and multidisciplinary cooperation to make sure these records are a concise and relevant resource for all stakeholders.

Reference

1. O’Donnell H, Suresh S. Electronic documentation in pediatrics: the rationale and functionality requirements. Pediatrics. 2020;146(1):e20201682. doi:10.1542/peds.2020-1682