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Editorials |17 February 2015

Clinical Documentation to Improve Patient Care

Thomas D. Sequist, MD, MPH

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Author, Article, and Disclosure Information
This article was published online first at www.annals.org on 13 January 2015.
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Expanded use of advanced electronic health records (EHRs) has many implications for the delivery of safe and effective patient care. The benefits of EHRs include decision support promoting medication safety, patient registries for preventive and chronic disease care, and improved patient engagement through integrated patient portals (1). However, these benefits are accompanied by drawbacks, with mixed effects on patient experiences of care (2), the potential for unintended harm related to electronic processes (3), and uncertain return on economic investment in complex EHR implementations (4). In this issue, the Medical Informatics Committee of the American College of Physicians (ACP) provides a policy analysis and recommendations for another important facet of EHRs: clinical documentation (5).
The ACP recommendations revolve around a key concept: Clinical documentation in the era of EHRs should first and foremost support the delivery of care that improves patient care and outcomes. To achieve this goal, providers, payers, policymakers, and EHR developers need to view clinical documentation as a fundamental tool for improving patient care rather than a regulatory burden or gateway for reimbursement. As such, clinical documentation must be integrated into our broadest strategies for ensuring that care is safe and effective.
Achieving this goal requires a vision for clinical documentation that moves beyond the concept of the static clinical note generated by a physician during an office visit or hospital stay. Instead, we must address 3 questions to realize a future of “high-value” clinical documentation. First, who...
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Sequist TD. Clinical Documentation to Improve Patient Care. Ann Intern Med. 2015;162:315–316. doi: https://doi.org/10.7326/M14-2913

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Published: Ann Intern Med. 2015;162(4):315-316.

DOI: 10.7326/M14-2913

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