News

Clinical Documentation and EHR’s: Substance or Form?

Published on May 21, 2013


Out of the many articles written about clinical documentation, one of my favorites isn’t about health information at all.  Yet I believe it is entirely relevant.

This article can be found on Fastcompany.com, titled Dee Hock on Management. For the unfamiliar, Dee Hock is the founder and former CEO of the Visa credit card association. If you are in management and haven’t read him – I recommend it. Love him or hate him, there is no arguing his success.

Here is a direct quote from Dee Hock:

“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

This quote is certainly relevant to clinical documentation, especially when we talk about the “quality” of health information in today’s changing health care environment.

There have always been many applications of the word “quality” within the health information domain. To HIM directors, quality might mean having the information they need to drive accurate medical coding and to be compliant with Joint Commission. Health care organizations implement Clinical Documentation Improvement (CDI) programs in support of patient care, but also in support of the revenue cycle.

CMS began providing financial incentives to physicians to provide more complete documentation as part of The Physician Quality Reporting Initiative (PQRI – part of the 2006 Tax Relief and Healthcare Act Section 101), now The Physician Quality Reporting System (PQRS).

The ARRA HITECH act includes reporting of quality measures as part of Meaningful Use requirements. The assumption is that the ability to track these measures automatically through the use of the EHR will lead to improved quality of care.  Of course reporting on these measures requires that they be documented.

If Merriam-Webster defines quality as “a degree of excellence,” then what does that mean for health information?  What is “quality” documentation?

“Health care is, at its very foundation, about physicians caring for patients.”

This is where Dee Hock comes in…

If we look at health information in light of Mr. Hock’s quote, what is the “substance” and what is “form”?

Health care is, at its very foundation, about physicians caring for patients.  Health information has endured from the time a physician first began writing down what he observed about the patient, what he did to treat the patient, and how the patient responded.

This information is the “substance” in this equation. It was the information the physician needed to care for a patient on a continuing basis, and to apply what he learned from the care of one patient to the care of a population. That is the “substance” that is the very foundation of health information and is the essence that endures over time.

How we capture, communicate, store, and disseminate that information – now that changes all the time. That is the “form” in this equation.

Unfortunately most conversations about health information today focus on new methods of “clothing” health information rather than on the information itself.  Is there too much focus on the “form” and not enough on the “substance”?

How do we preserve the substance of the past – the information needed for the care of the patient – while clothing it in the forms of the future – the EHR or other methods of enabling information exchange and communication?

“Can patient care really be completely represented by tagged data elements without the context contained in the narrative notes?”

How do we ensure that these new “forms” preserve and enhance what is best about health information? As we collect metrics around patient outcomes and processes, who is monitoring the quality of information as capture and distribution methods change?

Current conversations about health information often support the need to break health information into its smallest possible pieces – into metadata-tagged elements. But can patient care really be completely represented by these tagged data elements without the context contained in the narrative notes? Are discrete data points without context “quality” health information?  I myself have spoken to physicians who, while championing the advantages of the EHR, also express concern that they “lose the patient story in the computer.”

I hope that as conversations about healthcare reform become more focused on the health of the patient rather than on reimbursement for treatment of disease, that we can turn conversations about health information toward that same vision.

And for the more pragmatic and less dewy-eyed among us (someone accused me of being dewy-eyed recently – but I’ve been called worse), let’s look at another piece of this quote –

“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

So if through the use of HIT combined with our human knowledge and experience we preserve the “substance” in the health information equation, then that sounds like a win for all of us.
1 – Waldrop, M. Mitchell. (October 31, 1996). “Dee Hock on management.” Fast Company. Retrieved from http://www.fastcompany.com/magazine/05/dee2.html, December 18, 2007