This morning I woke up to the news that:
the Independent Hospital Pricing Authority (IHPA) (is requesting tenders) for a mobile app to improve clinical documentation and coding in patient medical records … that clinicians can use in their day-to-day work and … prompts clinicians to use accurate medical terminology when describing symptoms, diagnostic testing, results and treatment.
I can (almost) appreciate the intention behind this. But it’s frustrating that we’re such an environment. Though I don’t pretend to understand all the primary care clinical coding process and secondary use requirements.
The role of clinicians is to provide care for their patients.
If they are unable to record accurate clinical notes about their patients, the problem is with the software they are using.
I want my Doctor to record exactly what is wrong with me; Not worrying about compliance with secondary requirements like reimbursement or epidemiology analysis. I don’t want my clinical record to say “Liver disorders NEC“. I want it to say what the actual disorder is! And I have no doubt clinicians are capable of doing this without a computer. Though given this line in the actual tender:
clinicians are prompted to adequately document the patient journey to enable a coder to accurately code the medical record. The content will direct or guide clinicians.
A mobile app is not the correct solution for the problem here. There are already concerns about the PC being a third wheel in the Doctor-patient relationship, so adding a phone to the mix is unlikely popular…
Clinicians need access to systems that let them record what they need to. Ideally, in a way that allows others come in after and do whatever else needs to be done. Perhaps there’s room for improving the precision (rather than accuracy) of records?