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The Clinical Record: A 200-Year-Old 21st-Century Challenge

Michael S. Barr, MD, MBA
[+] Article, Author, and Disclosure Information

From American College of Physicians, Philadelphia, PA 19106.

Disclaimer: The views expressed are those of the author and do not necessarily reflect the views or policies of the American College of Physicians.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2235.

Requests for Single Reprints: Michael S. Barr, MD, MBA, Senior Vice President, Division of Medical Practice, Professionalism & Quality, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, mbarr@acponline.org.

Ann Intern Med. 2010;153(10):682-683. doi:10.7326/0003-4819-153-10-201011160-00015
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In this issue, Siegler examines the evolution of medical records at The New York Hospital and Maxson and colleagues describe federal efforts to support the broad implementation and meaningful use of EHRs through RECs. The editorialist discusses how these articles provide an opportunity to learn from the past as we design a future that provides new approaches to clinical information management and patient care.

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Musings of a PCP on the information overload resulting from the EHR
Posted on December 18, 2010
Timothy H. Tanner
Danville Health Center, Danville, VT
Conflict of Interest: None Declared

In response to Dr. Barr's editorial relating to electronic health records, I share some real-life consequences of the EHR.

I am a primary care provider working in a medical home practice that has used an EHR for 8 years (and hold no nostalgia for the paper record). I receive by automatic electronic transfer through our EHR results of lab and imaging tests, ED reports, consultant and subspecialty office notes and letters, lab and radiology reports ordered by other providers, inpatient progress notes, physical therapy notes....the list goes on. Although certainly not all inclusive, our EHR is becoming the principal repository of medical information for our patients.

I believe it is part of my responsibility as a primary care provider to review the incoming medical information, be it paper or electronic, looking for new test results, diagnoses, and changes in medications or treatment plans. However, the growing influx of information makes this task more challenging--more "rough" in which to hide the diamonds. Some of the challenge stems from quantity. There is no filtering of the in- coming information for clinical importance, nor any consistent method of highlighting changes.

Qualitative issues related to incoming medical information, whether electronic or on paper, are of more consequence. Sometimes buried within the text are new diagnoses, changes to chronic medications or requests to follow up on test results. Furthermore, sometimes it is difficult to determine if a consultant's recommendation is offered as a suggestion or a (confusing) way of stating his or her management plan.

The inundation of medical information is partly attributable to our EHR. Within our system of interfaces and automatic e-mail, we get all information from the various electronically connected sources, or we get none. Likewise, the problem of important information hidden within notes is partly due to the EHR. The "cut and paste" of templates populates notes with information important for each provider to obtain, but, in my opinion, generally unnecessary to communicate back to the referring provider.

Until the day of an EHR that automatically filters out redundant information, reconciles medication lists, highlights new problems and changes in treatment, we need to reexamine how clinical information is shared. The more important information needs to be presented in ways that cannot be missed or misinterpreted. Communication about diagnostic impressions, treatments, and who will do what, needs to stand out--by position of prominence, font change, dedicated headings, or separate documentation.

Conflict of Interest:

None declared

An Unnamed Barrier to Efficient and Effective Documentation - E&M Documentation Guidelines
Posted on December 28, 2010
Peter Basch
MedStar Health
Conflict of Interest: None Declared

To the Editor: In his editorial (1), Barr provides further background and context to Siegler's excellent article on the recent history of medical documentation (2). Both Siegler and Barr further impart wise cautionary statements as to the significance of medical documentation formatting. Siegler starts her article with the following comment, "Form dictates content, and...influences how we think about patients." Barr cautions against "(clouding) clinical records with extraneous, irrelevant, and repetitive documentation."

However, neither Barr nor Siegler discuss or even mention what many believe is the most significant driver towards obtuse formatting and irrelevant verbosity, the 1995 and 1997 Evaluation and Management Documentation Guidelines (DGs) (3). As anyone who has practiced medicine in the US in the past 15 years knows, DGs spell out exactly what medical documentation must contain for each level of service. Failure to include these required elements can result in downcoding of a claim, civil penalties, or even criminal charges for billing fraud. And because determination of these required elements is subject to external audit (which may be conducted by non-clinicians), physician have often responded by formatting their notes into discrete components (such as a separate ROS section), rather than following their clinical training and common sense; as well as over-documenting (a "pre-emptive defense" for coding audits). DGs don't proscribe concise and/or elegant narrative; but their existence provides a chilling effect that makes it unlikely.

The deleterious effects of DGs unfortunately extend beyond that of documentation per se; they have also had a negative impact on the functionality and output of electronic health records (EHRs) (4, 5). At least until recently, EHRs have been marketed to physicians primarily as tools to make compliance with coding documentation easier; which has meant producing documentation for the benefit of coding software and auditors - and unfortunately not for concise and elegant narrative.

Both Barr and Siegler appropriately call for near term next steps, such as returning to format and content that enables better and safer care, and detailing clear notes to the next provider of care. It will be difficult to follow their sage advice without amending or eliminating Evaluation and Management Documentation Guidelines.


1.Barr M. The clinical record: A 200-year-old 21st century challenge. Ann Intern Med. 2010; 153:682-683.

2.Siegler EL. The evolving medical record. Ann Intern Med. 2010; 153:671-677.

3.Kassirer JP, Angell M. Evaluation and management guidelines- fatally flawed. N Eng J Med 1998;339:1697-1698.

4.O'Malley AS, Grossman JM, Cohen GR, et al. Are electronic medical records helpful for care coordination? Experiences of physician practices. J Gen Int Med 2009:177-185.

5.Park T, Basch P. A historic opportunity: wedding health information technology to care delivery innovation and provider payment reform. Washington, D.C.: Center for American Progress, 2009. (Accessed at http://www.americanprogress.org/issues/2009/05/health_it.html.)

Conflict of Interest:

None declared

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