In this episode of Ask Dr. Mingle, Dr. Dan Mingle provides simple rules and concepts to increase your EHR efficiency and explains the limits of structured data. This episode is a continuation of last week’s conversation on how to build a Digital Strategy for High-Value Care.

Click play on the video below to hear Dr. Mingle’s thoughts on:

• The balance between structured and textual data and why he considers translation a key role for healthcare providers.
• How you can change your EHR workflows and concepts to save time, increase efficiency, and help you take better care of your patients.
• Essential concepts to remember when using your EHR lists and how to ensure your lists are complete and accurate.
• And why brevity and clarity are crucial driving concepts for all healthcare documentation.

Question One: Limits of Structured Data

Ann asks: “You said that healthcare organizations should have a digital strategy and that a digital strategy includes documentation as structured data instead of textual data. However, it seems that structured data is sometimes too limiting. Where is that balance point?”

I see translation as a healthcare provider’s key role:

• Translation of a patient’s complaints into structured medical concepts
• Translation of findings in structured terminology
• Translation of medical evidence into a management plan that fits the complaints and findings and that the patient can understand and manage

I think that two places in healthcare documentation require unstructured data:

• The chief complaint, in the patient’s words, is not structured and should not be.
  • Capturing this complaint in the patient’s words is valuable. It can help us identify when our initial translations are wrong. It can help us learn the range of concepts patients mean when making specific complaints.
• We must commit to assumed translations of complaints and findings to reach a diagnosis and treatment plan.
  • There is always an element of uncertainty. We can sometimes express the uncertainty in structured terminology, but if that isn’t possible, we can capture it with a textual entry to give the needed color to the decisions.

The key to using unstructured entries in healthcare is to always think: brevity and clarity. An excess of textual entries in healthcare data is inefficient and tends to hide or obscure important concepts and historical facts.

Question Two: Increasing EHR Efficiency

Carol asks: “Compared to when I used to dictate all of my healthcare notes, the EHR seems clumsy. It’s more of a barrier to taking care of patients than a tool of efficiency. Is it possible to grow to love my EHR?”

You will love your EHR when it is a time saver, helping you take better care of your patients.

We’ve come a long way in our digital evolution, but there is still a long way to go to optimally use our EHRs to help make healthcare more efficient and effective.

A few simple rules and concepts will help make your use of your EHR more efficient:

• Whoever collects the data should record it.
  • The closer it is to the source, the more accurate it will be. Every time you hand data off, the handoff introduces additional errors. When the medical assistant or nurse collects data, they should enter it in the record. Even clerical staff, usually the first contact with patients, can and should record things like chief complaints, in the patient’s words, with brevity and clarity.
• You should never re-enter something that is already in the record.
  • Redundant entries introduce errors and confusion, obscuring the historical facts you want to find quickly.

Our time in the medical record is better spent examining and correcting translations and assumptions rather than creating redundant entries.

I’m excited about recent changes in coding guidelines that allow us to bill based on complexity and/or time with the patient. It’s a great transition after decades of rules that promoted higher volumes of documentation as a proxy for time and complexity. With the new coding rules, by saving documentation time per patient, we can see more patients and essentially be paid for writing less.

Think of the old “Carpenter’s saying”: Measure twice, cut once.

To me, that means:

• Ask again.
• Test the accuracy of your previous assumptions and structured documentation.
• Change it when you know or suspect earlier assumptions were wrong.
  • Use structured entries or brief and precise textual entries to explain the changes.

The EHR is essentially a set of lists that reflects the unique health and healthcare-related records of each of your patients. The more complete and accurate those lists are, the more time it will save you and the more rapidly it will help you get to efficient and effective management plans.

Some advice for problem lists in your EHR:

• Keep them clean.
• If you resolve a problem with your patient, resolve the problem in your list.
• If chronic problems persist, make sure you reflect them in the list.
• You should reflect recurring problems as a new instance of a previously used code with a new onset and end date.
• Acute, resolved problems need to each have a beginning and an end.
• You should reflect changes in interpretation or the theory of disease with:
  • Entry of a new problem.
  • Retirement of the old.
  • And a brief, possibly textual, explanation of the change.

Medication lists have similar needs and dynamics as do problem lists:

• Keep them clean.
• You should link every medication to one or more problems it addresses.
• End medications whose courses have ended.
• You should reflect chronic medications as still in use.
• You should reflect recurring medications as a new instance of a previously used med with a new onset and end date.
• Every acute medication needs to have a beginning and an end date.
• You should reflect changes in treatment need to with:
  • Entry of a new medication.
  • Retirement of the old.
  • And a brief, possibly textual, explanation of the change.

The Importance of Brevity and Clarity for EHR Efficiency

Brevity and clarity are crucial driving concepts for all healthcare documentation.

Let me tell you a story from my experience to illustrate these principles.

When I first opened my private primary care practice in the 1980s, I stepped into a void created by the retirement of one doctor and the relocation of another from my small rural community.

The retired doctor told me about his practice, which sometimes demanded as many as 60 patient visits daily.

From my contact with his patients, I knew that despite the rapid pace of the practice, he was well-liked, deeply respected, and provided excellent care.

In my practice, all patients being new to me, I asked for many old records.

Many of the charts sent to me consisted of a pile of 3×5 file cards. Each card represented a visit. Each card epitomized brevity and clarity, with simple details like:

• Name
• Date
• Chief complaint
• Diagnosis
• Treatment

An example of this would be:

• John Doe
• May 13, 1978
• Sore throat
• Strep throat
• Penicillin 250 QID 10d

I was amazed and envious of the dynamic.

When I started in practice, a few decades of regulations designed to prevent fraud while documenting the complexity of each visit for billing purposes were adding words to each visit’s documentation without adding content or quality.

As I gained experience, I found that these were the data points for which I visually scanned visit documentation from later years. I rarely saw the need to read the rest of the visit notes. There was something that these notes lacked.

Part of the enormous value I see in an EHR is how it allows us to return to the efficiency represented by that old note card style, giving access to a better contextual richness from the lists.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.

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