Clinical Documentation – Friend or Foe

A friend of mine – and friend to all proponents of quality, efficiency and effectiveness – Gary David makes some great points about what “documentation” actually IS in his response to a comment about one of his blog posts. The commenter, ADavis, talked about a previous post by Gary in a HIMSS LinkedIn group discussion making some pretty strong statements about documentation being an inhibitor to progress, not being a collaborative tool – in a nutshell, not being useful.

I’m wondering what he meant – does he mean documentation in its substantive form – the way Gary defines it? Because if so I disagree with him – documentation IS the foundation upon which healthcare performs. It certainly is the tool through which clinicians collaborate. It is how clinicians find out about results of laboratory tests and studies. It is how they prescribe medications and order treatment. It is the source of how providers get paid for what they do. It is what protects the provider – and the patient – during litigation. And it promotes patient care. Imagine healthcare without documentation!

A woman who is very dear to me, someone more active and vibrant than most women half her age, has had a really tough couple of years recently. Ranging from the non-threatening, such as sinus problems and allergies, to more serious total knee replacements, to a very serious heart attack, and then even to cancer, this usually very healthy woman was plagued by health problems – and treated by teams of physicians across different specialties. Does anyone imagine that these doctors all got on the phone every morning and discussed her care? I doubt it. No one can convince me that documentation didn’t play a big part in the collaboration between the physicians that saved her life.

So – I can only imagine that ADavis’ concerns aren’t about documentation in and of itself. Perhaps ADavis is frustrated by the sometimes cumbersome documentation methods, maybe by the regulatory process, by perceived “requirements” for documentation, possibly by LACK of documentation or POOR documentation.

I can’t take credit for the comment Gary makes about me stating that documentation is “substance” and the method through which we “document” is only “form” but that idea comes from someone far beyond my reach.

As much as I would love to aspire to be a true thought leader, alas, what I am is just a fairly outspoken evangelist for the real thought leaders in health information and beyond…

I think it bears re-mentioning my very first posting on my blog where I talk about a quote from Dee Hock (VISA credit card association founder and former CEO):

“Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two is ruinous. Success follows those adept at preserving the substance of the past by clothing it in the forms of the future. Preserve substance; modify form; know the difference. The closest thing to a law of nature in business is that form has an affinity for expense, while substance has an affinity for income.”1

Granted, Mr. Hock was not talking about clinical documentation. But it rings true to me…the useful information that is provided and used by clinicians in the care of patients is the substance of this equation. HOW the documentation is captured, stored, shared, and accessed is only the form….

In a presentation Gary did at our M*Modal headquarters, Gary showed a film of a doctor using a traditional front-end speech recognition product to create documentation. He picked up a document from a fax machine and proceeded to read it into his front-end speech recognition software – he needed to get that information into his EMR. Someone in our audience pointed out that the faxed document could have been scanned and uploaded as a digital file into the EMR. But Gary pointed out – in the process of getting that information into his EMR, the doctor was also READING the information. Sure, someone in the office could have scanned it – but then when would the doctor have become aware of the information in that document?

Back in my physician practice days, I used to have to open the mail, take the typed paper reports sent from other physicians (yep, this was even before FAXING was commonplace), find the patient’s chart, paper clip the report onto the front of the chart, and leave the chart on the doctor’s desk. When the doctor had seen the report, he’d put the chart in the correct pile on MY desk and I’d file it away.

Inefficient? Sure it was – but just like the doctor reading his faxed report into his EMR, it ensured that the doctor SAW the new information.

How do we do this in our electronic world? What good does it do to have all this information available in an EMR if the doctors don’t see it? How do they know something new has been entered into that patient’s electronic record?

Let’s remember that any change we see in the transition from paper to the EMR/EHR is merely a change in form. The “form” is changing now. It will change again. What we need to be concerned with is the preservation of the substance – the information and its usefulness – while adapting to the changes in form.

Hey everyone – we transcription people have been in the documentation workflow management business for a long time. Surely we can use our knowledge and experience to address this type of challenge – to stay relevant into the future?

We need to be part of “preserving the substance of the past by clothing it in the forms of the future.” That is how we remain a vital part of the health information domain.

‘Til next time,

1 – Waldrop, M. Mitchell. (October 31, 1996). “Dee Hock on management.” Fast Company. Retrieved from , December 18, 2007

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