Brainstorming about the future of clinical documentation

January 3, 2013 by MassDevice

By John D. Halamka, MD

Dr. John Halamka

In 2013, I'm focusing on 5 major work streams:

*Meaningful Use Stage 2, including Electronic Medication Administration Records
*ICD10, including clinical documentation improvement and computer assisted coding
*Replacement of all Laboratory Information Systems
*Compliance/Regulatory priorities, including security program maturity
*Supporting the IT needs of our evolving Accountable Care Organization including analytics for care management

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I've written about some of these themes in previous posts and each has their uncharted territory.

One component that crosses several of my goals is how electronic documentation should support structured data capture for ICD10 and ACO quality metrics.

How are most inpatient progress notes documented in hospitals today?   The intern writes a note that is often copied by the resident which is often copied by the attending which informs the consultants who may not agree with content.    The chart is a largely unreadable and sometimes questionably useful document created via individual contributions and not by the consensus of the care team.    The content is sometimes typed, sometimes dictated, sometimes templated, and sometimes cut/pasted.  There must be a better way.

I recently attended a two day retreat to brainstorm about novel approaches to clinical documentation.