Note Bloat to Patient Encounter Recordings: Stuff Worth Considering

Note Bloat to Patient Encounter Recordings: Stuff Worth Considering

Today, I am touching on multiple topics that I found interesting over the past few weeks.

Medscape ran a story by Dr. Bruce Cohen at the end of May titled Choosing Our Terms: The Diagnostic Words We Use Can Be Harmful. This article centers on certain psychiatric diagnoses and how they are viewed as pejorative, like schizophrenia and personality disorders. I don’t object to retiring stigmatizing language, but we must keep in mind that ICD-10-CM has specific indexing. I would hate for us to start calling conditions by terms that no longer capture the diagnoses in codes and lose the ability to track and trend data. “Psychosis spectrum syndrome” will not code to schizophrenia unless the Coordination and Maintenance Committee makes some changes. Early adopters need to beware.

The next article was a treatise on copying and pasting – one of my arch-nemeses. I found it in STAT News, written by Sandeep Jauhar and titled Bloated patient records are filled with false information, thanks to copy-paste. Since I am in the middle of a book by Dr. Jauhar, I felt like he was a familiar friend. Most of it we have all heard, read, or experienced before – false information being propagated as “chart lore,” the bloating of the medical record, and how copying and pasting can be used to exaggerate the patient’s complexity to increase reimbursement. I was intrigued by one solution offered, however. They proposed having a single daily progress note that multiple physicians add to and edit. I am not sure I would give carte blanche to allow providers to edit someone else’s documentation, but they certainly could augment and notate. The fear I have is that providers who are prone to cutting corners might skimp on taking their own history, relying instead on the previous caregiver’s. It’s an interesting concept of collaborating, however. I think it might even make it easier for the reader, too.

The next article made me finally suck it up and purchase a subscription to the New York Times so I could access it. Steve Lohr wrote an article titled A.I. May Someday Work Medical Miracles. For Now, It Helps Do Paperwork. In the past, I had someone float the concept of recording the patient encounter instead of crafting documentation. I rejected the idea, because who would want to listen to all the superfluous details? The whole point of documentation is to separate the wheat from the chaff, making it accessible for the reader. If artificial intelligence (AI) summarizes and doesn’t include fabrications, which are referred to as “hallucinations,” this could be quite time-saving. But can the AI distinguish what is valuable and what is white noise? I’m not sure, but I do know this for a fact: if the providers don’t take the time to review and edit, the note can be just as bad as copied and pasted notes are now. I also dread the thought that the AI might synthesize a note but not attend to clinical documentation improvement (CDI) needs. Saving time generating a note only to lose time by having to respond to more queries doesn’t seem ideal.

The article also cited a homegrown technology at the University of Pittsburgh that “translates medical terminology into plain English at about a fourth-grade reading level.” This seems very practical now that patients have access to their notes under the Open Notes law. There is also indexing of medical moments so the patient can revisit portions of the provider-patient conversation. The providers also get the transcript, with links to the corresponding sections of the recording, so they can verify accuracy.

This article actually enticed me to offer my services on LinkedIn to AI technology companies that are developing it as a documentation tool. I want to be sure that documentation is enhanced, not degraded, by the technology.

I’d be supportive of any technology if the provider had taken my Dr. Remer’s Documentation Modules. They would have the understanding of why we create documentation, what constitutes good and risky documentation, and how to make sure the documentation advances the care of the patient. Memberships are available for individuals or for groups, and an institutional discount is available upon request. For more information, follow the link above.

Programming note: Listen to Dr. Erica Remer every Tuesday when she cohosts Talk Ten Tuesdays with Chuck Buck, 10 Eastern.

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Erica Remer, MD, FACEP, CCDS, ACPA-C

Erica Remer, MD, FACEP, CCDS, ACPA-C has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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