Medical Records Contain More Than Just Clinical Information

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I’ve been thinking a lot about how we deal with the information that is buried away in the electronic medical record and ultimately how it can be leveraged to promote the best clinical outcomes.  There are many publications that touch on this topic, among them the recently released Deep Medicine:  How Artificial Intelligence Can Make Healthcare Human Again by Eric Topol (it’s an extraordinary achievement, and I cannot recommend it highly enough).

But I can’t help but wonder if the focus on how we can access chart notes and what we might be able to do with the information in them misses an important factor.  The notes physicians enter into the medical record serve more than one purpose – they not only communicate clinical information, but also support billing and are a legal record of the encounter. 

In my first job, the medical director of the clinic where I was working assigned me the task of giving a lecture on billing and coding.  Sifting through the complexities of these documentation requirements was a daunting task. Sadly I learned while one might write a beautiful, nuanced note that would accurately capture the detail and spirit of a patient visit, unless it contained a certain number of elements from columns A, B, and C it would be kicked back by the billing department as inadequate.

“If it’s not documented, it’s not done,” are words that appear in the 2018 edition of the Medicare Guidelines for Evaluation and Management Services, the bible on how to document notes for various types of office visits. Each chart note must capture information on history, physical exam and medical complexity in a specific way.  It’s also noteworthy that the 2018 version says that it should be seen as a complement to, rather than a replacement of, guidelines that were published in 1995 and 1997. There is little flexibility in the way chart notes must be written in order to receive reimbursement for a patient visit and that hasn’t changed much in more than 20 years.

Billing requirements aren’t the only challenge.  As a 3rd year medical student, I attended a conference on medical charting. The speaker issued a warning that has stuck with me ever since:  “The chart is first and foremost a legal document.” I don’t know that every clinician would agree with that statement in its entirety, but I think most would at least understand the spirit of this caution.  The Rashomon effect is real, and it’s easy for physicians and patients to have different perspectives on how each might describe a clinical encounter. No matter how careful and complete a doctor attempts to be, knowing that they might have to testify in court about their notes is going to impact what and how they document the visit.

While I am excited about the possibilities that AI holds for medicine, I hope we don’t get too far out ahead of our skis. There will be improvements in natural language processing and other AI advancements that will help us extract data from medical records, but we need to be careful in how we interpret that data.

We need to remember that nonclinical factors such as billing and malpractice risk will continue to influence what is recorded in the chart.  Although maintaining information in EHRs about optimizing patient care should remain our top priority, we need to be mindful that this information will be used for other purposes as well.  

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