Excellent article published in the New England Journal of Medicine on the benefits of electronic clinical documentation.
NEJM - March 24, 2010: The United States is about to invest nearly $50 billion in health information technology (HIT) in an attempt to push the country to a tipping point with respect to the adoption of computerized records, which are expected to improve the quality and reduce the costs of care. A fundamental question is how best to design electronic health records (EHRs) to enhance clinicians’ workflow and the quality of care. Although clinical documentation plays a central role in EHRs and occupies a substantial proportion of physicians’ time, documentation practices have largely been dictated by billing and legal requirements. Yet the primary role of documentation should be to clearly describe and communicate what is going on with the patient.
Clinicians need to take back ownership of the medical record as a tool for improving patient care; such a move could have many benefits, including reducing the frequency of diagnostic errors. External requirements for EHRs should be minimized, and physicians, members of their support staff, and patients should be engaged in reengineering documentation, with the goal of building a more distributed, reliable, and content-rich yet succinct and efficient system. Diagnosing illness is one of our most important professional responsibilities, and patients justifiably expect us to perform this difficult task well. Electronic documentation represents a pivotal tool that can help us to fulfill this responsibility.