Is English the second language of medical documentation?
In a recent article written by the American College of Physicians, Yul Ejnes suggests that although English is the first language of Medicine, it has become the second language of EHRs.
"How and why did this happen? Most of it stems from the morphing of the medical record from a clinical tool to an audit and billing tool. The focus is no longer on capturing the patient’s history, examination, test results, and the physician’s thought process. Instead, today’s goal is to record as many things that were said or done as one can in order to justify the highest billing code, meet the performance measure, earn a high quality score, and lawyer-proof the record – and to do so in as little time as possible."
The article goes on to say:
"A progress note, whether for an office or a hospital visit, used to tell a story: what the patient said, what the examination showed, what the doctor thought was going on, and what the plan was to make the diagnosis or treat the problem, all of it written to help the physician take care of the patient and communicate with other physicians taking care of the patient. Today it is all about cataloging everything that was asked, everything that was examined, everything that was considered, and everything that was ordered (plus how long the visit was and how much of the time was spent on education and counseling). The goals are to code at as high a level of service as possible and meet the requirements of the “initiative du jour,” in a way that makes it as easy as possible for a non-physician reviewer to check off boxes. If there is a story to be found in today’s EHR-generated note, you often have to read between the lines to find it."
We disagree with the conclusion that It is time for an “English First” movement for medical documentation. Most User Experience and Content Strategy specialists would agree that it is best to present information to the user in a manner that is the most efficient and most effective for each user. This doesn't mean that the same information is presented to everyone. Just as Folksonomy and Taxonomy are related but are not the same. "English-First" does make sense for the final output of a progress note that is going to be seen by the patient, but for an insurance auditor, it may be too verbose to allow them to efficiently perform their role.
What is needed is a complete embrace of the User-Centered Design (UCD) approach where the needs of user drive the contents and structure of what is presented to them. Contact The Usability People for help implementing UCD across your organization.
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