With the proliferation of medical systems - EHR, LIS, and so many others - comes another boom: the widespread dissemination of documentation. Technological advances have made it easy now to create electronic reports capturing various elements of a patient's experience. Concerns about risk management, requirements of quality assurance, and needs of research spur adoption of these products, ensuring that every aspect of a patient's encounter is captured and can (hopefully) be used downstream. This explosion of reporting has led to what Neil Versel of Healthcare IT News calls "note bloat" - too many long winded reports and notes that only serve to boost quantity, not quality.
There are numerous reasons (most of them sensible, fair, and well-intentioned) for capturing so much information and having it in a report: As a guideline in treating others with similar issues, or use in research to perfect understanding or treatment of diseases; the pragmatic need to capture what happened to avoid any possible lawsuits; the ability to convey patient specific information to any other consulting physician or specialist; the necessity to properly capture what was done in order to make sure that the healthcare providers are properly reimbursed. These and other reasons all have their various merits for why physicians must capture their interactions, treatments, and impressions of their patients. But with multiple different systems - all working to one or more of those goals I just listed - physicians are now churning out more text than can actually be helpful.
Make no mistake - being comprehensive and thorough is of utmost importance in healthcare documentation. However, there is a point in practical day-to-day workflows where too much verbiage becomes a hindrance to effective medical treatment. As quoted in the Healthcare IT News piece
"It's been challenging for docs and healthcare systems in general … to produce a document that reflects the patient story in the most concise, complete and informational way," said Jody Cervenak, principal of Pittsburgh-based health IT consulting firm Aspen Advisors.
Meanwhile, according to this survey from Becker's ASC, the number one reason for procedures to be unexpectedly denied? A lack of information/documentation on services. How is this possible? How can physicians and facilities be bombarded by reams of text on the one hand, while simultaneously insurance companies aren't receiving the documents they need? Because what appears to be opposing issues is in fact two sides to one problem - substantive information is being drowned out or not being recorded.
By allowing for unstructured text, facilities are promoting endless paragraphs that may or may not address the most pertinent issues for the audience reading the reports. Referring or consulting physicians, coders, billers, patients all have to comb through these verbose sentences to find what they are looking for; even then, there's no guarantee what words will be used to convey the necessary findings. Synonymous phrases can appear in any place within these unstructured reports, making it easy for the reader to not know what to look for or where to look for it. Physicians are intimidated and awash in this sea of words, while coders can't find what they are looking for in order to process payments. Without any structure, mere anarchy is loosed upon the workflow.
Synoptic reporting, structured documentation, is the solution for both of these problems. With synoptic reporting, physicians are entering information in the same location, often using the same bank of words/responses. Electronic synoptic reporting allows enforcement of required fields - to ensure that specific pieces of information are included - and one can even design the report to include an overview at the beginning to highlight whatever is deemed to be the most important parts of the report (or 'synopsis,' hence the name). There is no loss of comprehensive reporting - readers will still have the same information, just presented in an easier to read format that allows them to find exactly what they want to know faster and without much difficulty. Instead of being bowled over by this avalanche of descriptions or potential chatter within the reports, physicians can easily look through to find the pieces of information they wish to find. Or, using the synopsis, physicians can understand the gist of the report instead of having to read multiple pages and still not be certain of a particular finding or diagnosis.
Billers, coders, and insurance companies will have all the necessary information captured and easily identified - included thanks to electronic required fields - to ensure proper reimbursement. Researchers will still have all of the data they could possibly want, but now freed from the confines of conversational sentences rampant with synonyms and tangents and without requiring abstractionists to pore over voluminous text.
For all of the reasons listed at the beginning, there is a purpose to all of the documentation; a method to the medical reporting madness. But good intentions rarely translate into practical solutions. The first phase has been completed, and we've identified what needs to be captured to satisfy each of those needs. Now comes the time when physicians, health information management personnel, and health IT developers work together to decide on how it should be captured. By using synoptic reporting, we maximize our time, preserve all of the information, and save our sanity as well.
In short, a place for everything and everything in its place works as well for data as it does for clutter. Physicians follow a consistent reporting structure but there are areas for free text that they can use to clarify or add to the standard fields. Synoptic reporting should make common information easy to find and understand, but should never prevent the addition of clarifying detail.