Rethinking clinical documentation for the EHR era

04 October 2016

By Sherree Geyer

Shaun Grannis, MD, can relate to the recent study in the Annals of Internal Medicine showing that physicians spend 37 percent of their time on clinical documentation in their electronic health records.

"Eight years ago when I was seeing patients, I would dictate for 90 seconds after every patient in free text and communicate all care provided," said Grannis, interim director of the Center for Biomedical Informatics at the Indianapolis-based Regenstrief Institute.

"Today, I fill out a five-page template for a sore throat that no one wants to read, with details that providers often miss," he said.

Peter Basch, MD, feels his pain.

"Our concern is that the voices of regulation, defensive medicine, billing and quality measure reporting have been so loud that the primary reason for documentation has been ignored," said Basch, senior director IT quality and safety, research and national health IT policy at MedStar Health in Washington.

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