Electronic Documentation in Pediatrics: the Rationale and Functionality Requirements Heather C

TECHNICAL REPORT

Electronic Documentation in Pediatrics: The Rationale and Functionality Requirements Heather C. O’Donnell, MD, MSc, FAAP,a,b Srinivasan Suresh, MD, MBA, FAAP,c COUNCIL ON CLINICAL INFORMATION TECHNOLOGY

Clinical documentation has dramatically changed since the implementation abstract and use of electronic health records and electronic provider documentation. aDivision of Academic General Pediatrics, Department of Pediatrics, The purpose of this report is to review these changes and promote the The Children’s Hospital at Montefiore and Albert Einstein College of development of standards and best practices for electronic documentation for Medicine, Bronx, New York; bPediatric Physicians’ Organization at Children’s, Boston Children’s Hospital, Brookline, Massachusetts; pediatric patients. In this report, we evaluate the unique aspects of clinical cDivision of Health Informatics, Department of Pediatrics, University of documentation for pediatric care, including specialized information needs and Pittsburgh Medical Center Children’s Hospital of Pittsburgh and School stakeholders specific to the care of children. Additionally, we explore new of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania models of documentation, such as shared documentation in which patients Drs O’Donnell and Suresh equally contributed as coauthors to draft, review, and revise the manuscript with input of all reviewers and the may be both authors and consumers shared documentation and among care Board of Directors; and both authors approved the final manuscript as teams, while still maintaining the ability to clearly define care and services submitted. provided to patients in a given day or encounter. Finally, we describe Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and alternative documentation techniques and newer technologies that could external reviewers. However, technical reports from the American improve provider efficiency and the reuse of clinical data. Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. fi Clinical documentation is de ned as the capturing and recording of clinical All technical reports from the American Academy of Pediatrics information, often in real time while the patient is present (eg, during automatically expire 5 years after publication unless reaffirmed, consultation, assessment, imaging, and treatment).1 However, clinical revised, or retired at or before that time. documentation has grown to encompass more than just provider notes at This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed the time of a patient visit. Patient care activities often take place outside conflict of interest statements with the American Academy of in-person encounters and include events involving care coordination and Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of communication with patients and caregivers. The records of such events Pediatrics has neither solicited nor accepted any commercial also represent clinical documentation. In addition, newer technologies, involvement in the development of the content of this publication. including patient portals, connected home monitoring devices, and DOI: https://doi.org/10.1542/peds.2020-1684 patient-controlled mobile devices, potentially enable patients and families Address correspondence to Heather C. O’Donnell, MD, MSc, FAAP. E-mail: to act as authors of clinical documentation, a title previously assigned only [email protected] to health care providers.2 Clinical documentation is primarily intended to facilitate the synthesis of To cite: O’Donnell HC, Suresh S, AAP COUNCIL ON CLINICAL patient information, develop medical care and wellness plans, and INFORMATION TECHNOLOGY. Electronic Documentation in communicate patient information. Initially, documentation was intended Pediatrics: The Rationale and Functionality Requirements. Pediatrics. 2020;146(1):e20201684 for sharing information among various health care providers but has since

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 146, number 1, July 2020:e20201684 FROM THE AMERICAN ACADEMY OF PEDIATRICS expanded to include communication especially when some of these technology to improve the care of with patients and their caregivers as requirements are redundant or not children as well as to mitigate the integral members of the care team. In relevant to the clinical narrative, and potential negative aspects. pediatrics, clinical care teams also can have the effect of blurring the include adolescents who may have understanding of the purpose of CONTENT AND STRUCTURE the right to manage their own a note. There is increasing recognition REQUIREMENTS FOR RECORDING reproductive health, substance use, that documentation burden can lead CLINICAL INFORMATION and mental health issues and the to clinician burnout, and new federal school systems that serve as legislation is aimed at developing Similar to what has been emphasized important caregivers for pediatric strategies to reduce documentation in AAP policy statements and 9–14 patients. Clinical documentation also burden.4 technical reports, an Agency for serves other important roles, Healthcare Research and Quality Electronic clinical documentation 15 ’ including the record of patient care technical brief, and the Children s may also be more onerous than using 16,17 and services provided for billing EHR Format, pediatric care paper. Efficient typing and navigation purposes, a means to protect the legal providers need certain core of the electronic record may not be interest of providers and patients, functionalities in EHRs, including the skills possessed by all providers. a resource for research data for ability to document in a manner that Documentation tools such as copying quality monitoring and improvement, supports and facilitates the care of functions, templates and scripts and an educational tool for health pediatric patients. Templates or (allowing for clicking rather than care provider trainees.3 similar tools designed to guide typing), or the importation of data providers through the task of The transition of clinical from other areas in the medical documentation should facilitate documentation from paper to record can alleviate some of the longitudinal, preventive, team-based, electronic health records (EHRs) has burden. However, these tools may and age- and condition-specific care provided many positive opportunities introduce new unintended central to the core of pediatric in clinical care and documentation consequences of their own, including medicine (Table 1).18 In addition, but has also introduced new increased length and decreased pediatric care providers have long “ ” challenges. Most importantly, effectiveness of notes ( note bloat ) been on the forefront of family- 5–7 electronic clinical documentation is and inaccurate documentation. centered care,19 but many EHRs lack more accessible and legible than The American Academy of Pediatrics the ability to support the hallmarks of paper records, may include more (AAP) has addressed several topics this aspect of care, such as team- structured data elements contained related to EHRs, including electronic based documentation and elsewhere in the medical record, and prescribing systems,8 health documentation of familial is available remotely to health care 9 information technology and the connections. For example, familial providers, patients, and other medical home,9 standards for health linkages in the EHR and the ability to stakeholders. information technology to ensure share certain parts of documentation, One downside with electronic adolescent privacy,10 pediatric such as family and social histories, documentation is that providers may aspects of inpatient health across family members could increase be overwhelmed with large amounts information technology systems,11 the robustness of this information of textual and tabular data. In and electronic communication of the and strengthen the delivery of family- addition, nonclinical stakeholders health record and information with centered care (Table 1). This feature may have a more direct influence on pediatric patients and their could also serve as a method to the design and content of clinical guardians.12 Although these areas reduce redundant documentation. For example, cover aspects of electronic documentation tasks. electronic documentation tools can documentation, there is a lack of remind or even require (required a single unified AAP policy statement Discrete Data fields, forced fields, or hard stops) an or technical report that provides an Similar to other medical specialties, author to include specific items in his overall view of clinical documentation the documentation needs of pediatric or her documentation. Interventions of pediatric care. In this technical providers include both discrete on paper were much less invasive report, we aim to review electronic (conforming to a predefined or (education or reminders that could be clinical documentation in pediatrics conventional syntactic organization) avoided) and likely less effective at and provide background information and nondiscrete documentation changing documentation behavior. for the recommendations in the needs as well as the need for some This additional input can lead to accompanying policy statement13 to flexibility between the two.20 The increasing documentation burden, maximize the benefits of such value of discrete data includes

Downloaded from www.aappublications.org/news by guest on October 2, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Clinical Documentation Framework Based on Core Components of Pediatric Care Core Component of Pediatric Examples of Supporting EHR Documentation Care Longitudinal Support documentation over the life course of the patient: attainment of developmental milestones (even outside typical norms); physical growth (growth charts); and serial immunizations (eg, DTaP vaccine No. 2). Preventive Support the attainment, documentation, and review of measures designed to maintain health: immunization schedules and screening tools and testing. Age based Document and review data based on patient age: screenings, testing, and measurements and anticipatory guidance. Pediatric condition specific Document and review data based on patient conditions: dedicated growth charts for patients with conditions affecting growth parameters (eg, Down syndrome, prematurity) and documentation templates that guide assessment of patients with specific conditions (eg, evaluation of asthma severity or control for patients with asthma). Patient and family centered Documentation supports the family unit and includes patient and family input: shared or linked mother-infant records to support perinatal care and documentation, shared family and social history documentation across family members, integrated patient- and family-generated data and/or information, supporting adolescent confidentiality, making information such as immunization records available to patients, families, and their providers regardless of the site of receipt. Team based Shared documentation tasks across health care provider types, primary care and specialty physicians, and health care settings (ambulatory, acute care, and long-term care). DTaP, diphtheria and tetanus-acellular pertussis. relatively easy use and reuse for still may be clinically relevant, and but retrieval and display of this clinical decision support, quality the flexibility should be present to information also requires careful measurement, research, or reporting allow for inclusion of these data consideration and build. Data display to regulatory agencies.2 For example, alongside other discrete data in that should be sensitive to both pediatric discrete data can be used to support category, so important information is providers’ needs and patients’ clinical decision aids that are valuable not missed. conditions. As examples, to pediatric care providers, including immunizations should be displayed Examples of discrete data of health maintenance schedules that by vaccine components rather than importance to pediatric care address vaccinations and screening by brand names or combinations, and providers include vital signs, growth on the basis of AAP preventive care vital signs should be displayed with parameters, immunizations, guidelines.21 However, free-text or their corresponding age-, sex-, height- screening tests (eg, hearing tests, narrative documentation provides its , and/or weight-based percentiles. visual acuity testing, and own benefits because it allows for developmental and mental health nuanced documentation for Data elements should also be questionnaires) and validated scoring individual patients, which is critical displayed on the basis of patient- and screening tools (eg, Apgar score, for patient-centered care. specific conditions, such as growth Pediatric Early Warning Score, charts for prematurity and Down Pediatric Quality of Life syndrome. Other examples include The need or desire for discrete data 11,14,17 entry can have negative impacts on Inventory). The discrete nature immunization displays, the ability to the relevance and clarity of clinical of the documentation of some of document new vaccines for patients documentation and may increase these items also makes them suitable who have not responded to the documentation burden for health care for device integration and for original vaccine series, and patients providers.20 Furthermore, the machine-readable technology that who have received a stem cell required components for some streamline documentation and data transplant. In addition, there is a need structured data entry for clinical entry. For example, the use of for these displays to rapidly evolve information can result in an inability barcoding for vaccine administration with evidence-based updates, such as to record data that do not fit neatly eliminates the need to manually the recommendation to use the World into the structured syntactic document the lot number and Health Organization growth charts for organization or that are partially expiration date for every vaccine. children 0 to 2 years of age rather incomplete or unknown. For instance, Alternative technologies such as these than those of the Centers for Disease some EHRs may limit the recording of can both serve to reduce Control and Prevention23 and new documentation burden and reduce immunization receipt or current 22 guidelines for the management of documentation errors. 24 medications if the exact immunization hypertension. Delays in updates date is unknown or the patient or may lead to the persistence of caregiver does not remember the Data Display and Standards suboptimal or out-of-date care. name of a medication. This Documentation should only have to However, even if optimal and current information, although incomplete, be entered once for these key metrics, care is provided, any out-of-date

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 146, number 1, July 2020 3 information populated in the systems (M.J Curren, V.K. Reddy, stakeholders and plays important documentation could be personal communication, 2017). roles in supporting regulatory misinterpreted. For example, the requirements, legal protections, provider made a clinical decision Managing Information Overload medical research, quality using the new hypertension The rapidly expanding volume of improvement, and medical education. management guidelines and blood clinical documentation and its Although important, the needs of pressure percentiles, but the old accessibility potentially across these additional stakeholders often percentiles and/or guideline a patient’s lifetime regardless of the add to the complexity and amount of information still populate into location of care has important clinical information captured and contained the note. benefits, but it has also introduced within EHR systems. a new problem in clinical care: Importantly, the value of discrete data information overload. The concern is Regulatory Requirements is enhanced if the data can be used that the large volume of clinical Developing and implementing clinical across health care institutions and information can lead to the inability templates, customized electronic organizations. For example, if of a clinical care provider to quickly forms, and computer-assisted coding ’ patients immunization records were retrieve appropriate diagnostic and for patient encounters may result in shared seamlessly across EHRs and therapeutic information when needed more complete evaluation and vaccine registries, the data at every and may lead to a clinical care management (E&M) coding. There is location could be more robust and provider overlooking important evidence that the use of EHRs may accurate. In addition, the task of clinical information. Technological have contributed to increased use of documenting immunization histories solutions are likely necessary to higher-level Current Procedural into separate systems would be mitigate this problem and maintain Terminology (CPT) codes, particularly eliminated. For this reason, the AAP clinical care efficiency and value, in the emergency department and other volunteer organizations including integrating graphs, tabular setting.30 Although it is important should continue to support the data, knowledge management tools, for EHR documentation tools to creation and alignment of clinical smart search engines, links to Web- guide and facilitate providers in 25,26 data standards. The integration of based resources, and customized documenting pertinent information, these standards within various EHRs menus.29 Functionalities that the EHR should not promote the would increase the likelihood that promote a more hierarchal display of inclusion of extraneous or irrelevant individual organizations would adopt data and promote the value of the information that then can be used to these standards and would promote synthesis of these data into select a more complex CPT code. technical interoperability. information are needed to achieve The Office of the Inspector General this goal and mitigate information holds individual physicians overload. For example, as the number Note Structure responsible for all professional coding of notes per patient continues to in their name regardless of the EHR Given the evolution of electronic increase, standard naming tools used or other coding support charting and regulatory requirements convention, filtering, and semantic used to select the CPT code. For this of documentation, note structure and searching functions may help reason, it may be useful for pediatric the elements that should be included providers access necessary care providers to familiarize in various clinical note types (eg, information in a timely manner. ambulatory visit note, inpatient themselves with common CPT codes Whenever possible, usability and progress note, and operative report) rather than relying solely on EHR information design should be an 31 need to be constantly reviewed. The tools for CPT selection guidance. essential part of the EHR certification increasing length and limited use of The Centers for Medicare and process. There should be a focus on notes argue for a more streamlined Medicaid Services (CMS) has begun graphical visualization of numerical structure in which the most the process of revising the E&M data. Custom development of patient important clinical information is requirements in this new electronic summaries for various provider types 32 more readily found.27 A solution era. and care settings requires effort but framework to address this pervasive can be valuable. In addition to E&M coding issue is a modified subjective, requirements, processes must objective, assessment, plan (SOAP) be in place to ensure that the note (Fig 1), which retains the DOCUMENTATION FOR ADDITIONAL documentation for the health original SOAP note structure from the STAKEHOLDERS information used in care, research, paper-based era28 but mitigates Electronic clinical documentation also and health management is accurate, known concerns of electronic note serves important functions for other complete, and timely because clinical

Downloaded from www.aappublications.org/news by guest on October 2, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS FIGURE 1 Evolution of SOAP Note 2.0 from known SOAP structure. documentation serves as a key record objectives that have been developed together on electronic documentation to provide legal protection for for both ambulatory and inpatient design, implementation, and providers and patients. hospital quality reporting programs improvement as well as the policies Documentation standards should and must be reported to the CMS.33 A and procedures surrounding include recommendations regarding robust electronic documentation documentation and EHR use. The goal the use of electronic documentation system also creates the platform for should be complying with billing, functionalities, such as copy and patient care–based research and coding, and payer guidelines and paste, copy and forward, and quality improvement projects that are providing data for quality reporting automated insertion of data crucial for pediatric care providers to programs but also following best documented elsewhere in the EHR. provide safer, higher-quality care.34 practices for electronic Misuse of these functionalities can The data used for these purposes documentation.35 In addition, it is result in inaccurate, outdated, or often require more structured or crucial that the documentation irrelevant information, which may specific data entry. Effective burden placed on providers is not too lead to significant quality of care and reporting, quality measurement, and high, and as much as possible, data medical liability issues as well as the medical research depend on accurate solely necessary for other upcoding concerns noted previously. clinical documentation. In the stakeholders should not disrupt the However, it is important to recognize development of new quality or clinical narrative. that with proper use, these research measures existing data functionalities can save time and should be used whenever possible Documentation as a Vehicle for enhance documentation. After and primary data entry should not be Medical Education reviewing the literature on safety required explicitly for that measure, risks related to copying and pasting, thereby avoiding additional The steady shift of health care the Partnership for Health IT Patient documentation burden by providers. documentation from paper to Safety made 4 recommendations that When making decisions about electronic over the past 2 decades has could improve the safety of its use: additional data elements required or had an impact on the learning process making copied and pasted text readily requested from clinicians, we should of medical students and pediatric identifiable, referencing the text’s take this fact into consideration and residents and fellows. The EHR is an origin, providing education on its safe be judicious in implementation. essential part of the daily work of use, and having practices in place to medical students as they care for monitor its use.7 As electronic clinical documentation children and can also serve as an and documentation tools continue to interactive learning tool by providing Clinical documentation is also an evolve, it is key that clinicians, clinical clinical decision support and ready integral data source for reporting, informaticists, health information access to the medical literature. quality improvement, and research. management professionals, and Medical interns are estimated to For example, electronic clinical quality, regulatory reporting, spend 40% of their time dealing with quality measures are a set of quality research, and billing specialists work EHR systems,36 and in academic

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 146, number 1, July 2020 5 medical centers, residents are a key improvement efforts in teaching standardization of documentation source of clinical documentation. hospitals should include input of essential for this process for schools trainees. and child care centers across the Clinical documentation, itself, is an country. In addition, efforts should be important learning objective of UNIQUE STAKEHOLDERS FOR made to enable sharing of this medical training, and close attention information electronically with ’ PEDIATRICS should be paid to trainees parents and the school system and understanding of the purpose of Schools direct communication between health medical documentation and proper Pediatricians have a unique care and education providers. Privacy, documentation technique in the fi relationship with school systems consent, and security speci cations electronic environment. In teaching fi because children spend much of their would need to be de ned for this institutions, trainees may be the time at the school and teachers and information exchange. primary documenters of clinical care school nurses serve as important because the CMS allows attending caregivers for children. Federal law, Adolescents providers to verify both resident specifically the Individuals with physician and medical student notes Pediatric care providers need to Disabilities Act40 and section 504 of rather than redocumenting the document information regarding the Rehabilitation Act of 1973,41 work.37 Trainees are often recipients adolescent mental health, substance ensures that all children, regardless of of heavy workloads and may be more use, and reproductive health so that it disability, have a right to free and susceptible to some of the pitfalls of can be used for their care and public education that meets their electronic documentation.5 Medical communicated with other providers. needs. Schools are responsible for the school and residency programs However, as discussed in an AAP care of any child’s medical needs at 10 should prioritize informatics policy statement, this information is school and are also important resources to aid and assist in protected by federal and state laws. partners with pediatric care designing curriculums and providing Although the adolescent is a minor, in providers in ensuring that children instruction on the best practices for some states, certain information with learning disabilities or clinical documentation. Mentoring cannot be shared with parents or developmental delays receive ’ physicians should continue to provide guardians without the adolescent s evaluations and appropriate feedback to their trainees regarding permission unless there is a risk of education and therapies. 10 their documentation and proper harm. Many EHR systems lack the fi mastery of the use of the EHR system. There is a vital need for school technology to segment or lter systems and child health providers to confidential clinical data to prevent In the 2013 Accreditation Council for communicate and share relevant inadvertent disclosure to Graduate Medical Education common information in a bidirectional manner. unauthorized parties, including the program requirements, use of Currently, much of the sharing of this protected information information technology is listed as communication between schools and with parents in written form or 10,12 one of the competencies under medical providers takes place via electronically through a portal. practice-based learning and parents, who communicate between Unless a nationwide consensus on 38 fi improvement. There are speci c the 2 parties either with verbal adolescent confidentiality issues is suggestions for EHR-related information or by transporting paper reached, there would also need to be enhancements to core competencies, school forms completed by educators flexibility in EHR settings regarding such as maintaining accurate problem and child health providers back and adolescents to account for state and medication lists within the EHR forth. This method leads to excessive variations in laws. to facilitate multispecialty care, which work for parents and providers and fi exempli es the core competency of presents multiple opportunities for 39 NEW SHARED DOCUMENTATION systems-based practice. error. In addition, the variability and PARADIGM Trainees are also in a unique position constant changing of school forms to advance health information required by private and public Shared Documentation With Patients technology. Trainees who are schools and child care centers causes and Families fi technically savvy and perhaps the great dif culty for health care Historically, the patient medical heaviest users of the EHRs can providers and for the potential use of record, including clinical provide important feedback on EHRs to aid form completion. documentation, has been owned specific areas in which the EHR Communication between schools and and held by medical providers and functionality can be improved. EHR health care providers could be facilities, with access granted by and electronic documentation facilitated by the streamlining and request to patients as per regulations

Downloaded from www.aappublications.org/news by guest on October 2, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS in the Health Insurance Portability providers and to substantiate billing Another potential value of PGHD is and Accountability Act.42 Until more are needed. In addition, because the capture of important information recently, most patient requests for a significant portion of parents in that may otherwise be missed during medical records were handled in America have basic or below-basic a short visit and the empowerment of person and/or through a process levels of health literacy,50 their ability patients to have a significant voice in of written request. to make use of these notes to improve their own health care. Early-use cases their child’s care should be in pediatrics include previsit surveys This paradigm is changing rapidly investigated. to tailor a clinical visit and with improvements in patient portal questionnaires to assess and track technology and with the requirement It is also important to recognize that development, quality of life, and to share information electronically the sharing of clinical documentation indicators for various chronic medical with patients as part of the Promoting between providers and patients could conditions.53 Interoperability Program also reduce documentation burden 43 requirements and the 21st Century for clinical providers. Notes and Shared Provider Documentation Cures Act.44 In general, there is written patient instructions given to growing support that although the the patient (eg, after-visit summary Communication among providers is medical care establishment remains and discharge instructions) are often an important function of clinical the steward of the data, patients similar but may be crafted separately. documentation. For example, to should have more control over their If one document could serve both enable successful communication clinical records. Although current purposes, it could eliminate between a referring primary care meaningful use criteria do not redundancy and ensure that provider and a medical subspecialist explicitly require the sharing of providers and patients communicate or surgical specialist, the reason for specific clinical documentation, such the medical plan effectively. consultation and urgency should be as office visit notes, daily progress clear and readily available. This notes, or discharge summaries,45 Patient-Generated Health Data information can then be reviewed by a few institutions have begun doing There is an opportunity in pediatrics specialty providers and their support so and have found this sharing to be to capitalize on patient-generated staff as the appointment is being well received by patients. A study at 2 health data (PGHD), defined as scheduled and at the time of the visit. institutions in 3 geographic areas “health-related data—including Similarly, the specialty assessment (OpenNotes) revealed improvements health history, symptoms, biometric and plan should clearly delineate the in patient-reported medication data, treatment history, lifestyle plan, including which provider is adherence, engagement, and choices, and other information— responsible, and needs to be clearly satisfaction after the institutions created, recorded, gathered, or communicated to the referring 54 began sharing provider notes inferred by or from patients or their provider and the patient. 46 electronically. designees (ie, care partners or those Although primary care providers, who assist them) to help address The ease with which patients can now medical subspecialists, surgical a health concern.”51,52 There is access their health records and specialists, emergency physicians, growing evidence that PGHD have information electronically could lead and hospitalists may all provide care value to both patients and to a more shared model of EHRs and for the same medical problem for providers.52 The application of PGHD clinical documentation. Although a given patient in the same EHR in pediatrics should continue to be concerns have been raised about the system, their documentation, explored and evaluated. possibility of patient including the assessment and plan, is misunderstanding or worry regarding The value of PGHD includes the usually housed in separate notes. the information contained within the possibility of improving efficiency by Although distinct notes for each record,47 the rates of this occurring, the sharing of documentation tasks encounter are necessary for clearly as reported by patients with access to that would otherwise fall on documenting occurrences at a given clinical notes, were low.46,48 Even so, providers and support staff or the visit or on a given day, models for providers should be educated time taken during the visits for shared documentation should be on ways to document without patients and families to complete explored as a potential way to using needless medical jargon, paper forms or questionnaires.17 This improve communication among abbreviations, and judgmental value may only truly be reaped, providers. language.49 Guidelines on creating however, if the data are safely and patient-centric notes without losing seamlessly integrated within clinical Problem-Oriented Charting the documentation’s role as workflows and EHRs in a manner Shared patient medical problem lists a communication tool among acceptable for patients and providers. and problem-oriented charting could

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 146, number 1, July 2020 7 allow providers to view plans by all codes may be insufficient to reflect multiple concentrations of the providers related to a particular the clinical picture. For example, same liquid medication. However, medical problem. However, the use there are limited codes available for even in the absence of knowing of problem-oriented charting has working diagnoses and for problems every detail, providers should be able challenges, including problem list related to social determinants of to record partial medication incompleteness and inaccuracies. An health. In addition, multiple diagnosis information alongside all other institution’s use of problem-oriented codes or problems are often used active medications. Successful charting or linkages between billing for interrelated conditions, raising electronic medication documentation data and problem lists was associated the concern that problem-oriented and management requires with higher rates of problem list documentation does not help appropriate context, properly completeness.55 manage the patient as a whole designed tools, and attention to individual.59 implementation.61,62 In addition, the success of maintaining accurate problem lists Medication Documentation and for patients, as well as problem- EVOLVING CLINICAL DOCUMENTATION Management oriented documentation, is associated METHODS Another example of shared with a culture in which primary care The technologies and methodologies documentation is medication lists. physicians and medical subspecialists associated with electronic The idea behind shared medication and surgical specialists share documentation continue to mature. 56 documentation is to build on existing responsibility for the problem list. New tools should be evaluated for medication lists that multiple However, actual completion of the their ability both to improve clinical fi provider types across clinical settings problem list is dif cult to both care and to alleviate provider contribute to rather than maintain support and enforce, and that culture documentation burden. For instance, separate lists, thereby reducing the may not exist at every practice or the scope of clinical documentation harm caused by medication institution. There is some evidence has expanded beyond textual discrepancies during patient that primary care providers are rendition. Images (rashes and wound transitions.60 However, similar to responsible for the clear majority of care), audio files (abnormal heart and shared problem lists, not all providers problem list documentation, and breath sounds), and video files believe they have ownership over the although primary care providers (seizures and endoscope findings) entire medication list. There is an believe medical subspecialists should may be useful adjuncts in the EHR. inherent issue of medical contribute to the problem list, These alternative media could prove subspecialists preferring to reconcile medical subspecialists believe it may more valuable to clinical care than medications that are only relevant to be an incursion on the primary care text description of the findings and ’ 57,58 their scope of care. Despite this, provider s territory. In addition, could reduce some documentation studies have revealed that some medical subspecialists are load. However, more information is a structured, systemwide likely to prefer documenting in a needed about how clinicians can intervention can be successful in more systems-based format (eg, ICU include these media in EHRs using achieving medication reconciliation providers who care for more children existing or future technology in compliance.59 with active multisystem issues). a way that complies with the Health Providers may have differing needs One medication list may not be able Insurance Portability and for the information granularity level to serve all purposes of medication Accountability Act. Another of any one given problem. Guidance documentation, however. For example is using alternative EHR and policies regarding how to instance, there is a difference data sources, such activity logs, to effectively share problem lists and between prescribed medications and justify payment for services and other shared documentation are medications taken by the patient, and eliminate the need for redundant necessary to support this new both are important information to documentation. The use of paradigm. maintain. In addition, many different types of media and EHR data Although linking billing with problem medication lists require structured sources as clinical documentation lists is associated with more complete entry of the medication name, needs to be incorporated into E&M problems lists, basing a patient’s concentration, dose, route, frequency, guidelines. problems on billable diagnosis codes and dispense amount to prescribe (eg, the International Statistical medications and refills. There is Speech Recognition Classification of Diseases and Related also another layer of complexity Speech (voice) recognition Health Problems, 10th Revision) can when documenting medications software is a growing technology that introduce additional issues. Diagnosis in children, in that there may be has the potential to improve

Downloaded from www.aappublications.org/news by guest on October 2, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS the efficiency of clinical Technology to Enhance Data Reuse LEAD AUTHORS documentation. As speech recognition New technologies could reduce Heather C. O’Donnell, MD, MSc, FAAP software continues to improve, it may documentation tasks by eliminating Srinivasan Suresh, MD, MBA, FAAP offer advantages over standard the need to document discrete dictation and documentation by using information by enabling the reuse of COUNCIL ON CLINICAL INFORMATION a keyboard and mouse. However, text for research, quality metrics, and TECHNOLOGY EXECUTIVE COMMITTEE, further investigation is needed to clinical decision support. Effective use 2018–2019 assess its impact on documentation 63–65 of natural language-understanding Emily Chui Webber, MD, FAAP time and error rates. The tools, in which unstructured narrative Gregg M. Alexander, DO maturity and increasing information is converted into Sandy Lee Chung, MD, FAAP fi Alexander M. Hamling, MD, MBA, FAAP use of arti cial intelligence a structured form, could increase the computing techniques has greatly Eric S. Kirkendall, MD, MBI, FAAP amount of data usable for other Ann M. Mann, MD, FAAP improved speech recognition purposes without increasing Heather C. O’Donnell, MD, MSc, FAAP capabilities. documentation burden on providers Reza Sadeghian, MD, MBA, MSc, FAAP or favoring heavily structured notes Eric Shelov, MD, MBI, FAAP Scribes 69 Srinivasan Suresh, MD, MBA, FAAP over clinical narratives. For Andrew M. Wiesenthal, MD, SM, FAAP In addition to technological solutions, example, natural language- the use of physician extenders or understanding tools can enable the scribes has been considered as use of free-text information to drive LIAISONS a possible solution to alleviate clinical decision support.70 Dale C. Alverson, MD, FAAP – Section on physicians’ documentation burden. A Telehealth Care – scribe’s core responsibility is to Francis Dick-Wai Chan, MD, FAAP Section on Advances in Therapeutics and Technology capture accurate and detailed CONCLUSIONS Melissa S. Van Cain, MD, FAAP – Section on documentation of the encounter in Pediatric Trainees a timely manner. The general duties Electronic documentation is now the of a scribe may include assisting the norm for the care of children in most STAFF provider in navigating the EHR, industrialized countries. However, responding to various messages as there are still struggles to fulfill the Lisa Krams directed by the provider, locating many roles of electronic information for review, and entering documentation. Strategies to meet information into the EHR. It is these multiple, often competing needs ABBREVIATIONS imperative that all entries regarding have shifted from replicating paper AAP: American Academy of a patient’s health information be documentation to exploring different Pediatrics completed in the presence of and at models that may better suit these CMS: Centers for Medicare and the direction of the provider. It is also requirements and achieve maximum Medicaid Services important that authentication of each value for pediatric providers and for CPT: Current Procedural entry be completed in a timely the care of children. Examples include Terminology manner as defined by a practice’s shared documentation and E&M: evaluation and management policies and regulatory medication management. EHR: electronic health record requirements.66 Research in this area Documentation improvement is PGHD: patient-generated health is limited and has shown a multidisciplinary venture that data discrepancies in whether scribes have should include input from clinical, SOAP: subjective, objective, led to improvements in provider research, regulatory, and education assessment, plan efficiency and satisfaction.67,68 stakeholders.

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no ﬁnancial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conﬂicts of interest to disclose.

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