The 5 C's of Charting

For years, I've advocated that the highest purpose of a chart is to communicate a patient's health information to other providers. But the requirements placed on a chart don't end there. What is the full list of the expectations of a high-quality chart?

First and foremost, our top goal as healthcare providers maintaining and sharing clinical charts is effective COMMUNICATION (#1 of our 5 C's).

The remaining four items on our list of what needs to be communicated:

  1. CARE
  2. CODING
  3. COMPLIANCE
  4. CLINICAL RESEARCH DATA

Let's examine each of these a bit further, and expand the assessment to the question of to whom we communicate these four items:

CARE

  • What: health problems and threats with both historical context and detailed and explicit forward-looking plan of care
  • Who: individuals who currently and in the future share responsibility for implementing, monitoring, revising and refining a plan of care

CODING

  • What: discrete, defined, billable activities and services; the "sku's of healthcare" as it were
  • Who: the entity that is responsible for reimbursement of the service (in an efficient health care system, future patients will want to understand this information as well, but that is the subject of a future post)

COMPLIANCE

  • What: supporting evidence of "high-quality" from varied viewpoints of a long list of "Who" individuals identified in the next bullet (I believe that the length of the list that follows drives much of the craziness in health information technology, but sorting this out will ultimately drive tremendous value)
  • Who:
    • Peers and other providers — were the services provided according to accepted clinical quality standards?
    • Payers — are the services covered and are they documented appropriately?
    • Clinical researchers — were protocols adequately defined, documented, and adhered to
    • Attorneys — was the care appropriate? (this view is closely related to that of the providers, but with a more adversarial/accusatory perspective)

CLINICAL RESEARCH DATA

  • What: a continually evolving and expanding collection of codified and structured information about the patient, their care, and their environment
  • Who: Individuals and organizations seeking to find the causes and contributors to all manners of medical and traumatic maladies with the goal of reducing the ultimate burden of disease and injury

My personal experience as a clinician (emergency physician) and a health informatician (Chief Medical Information Officer at Afoundria) is that the vast majority of EHRs and supporting health information technology (HIT) deployed in health systems today have relegated the effective communication of CARE to the "back seat". What should be secondary goals related to CODING, COMPLIANCE and CLINICAL RESEARCH DATA have come to dominate both the process (charting) and the end product (the chart).

Afoundria is committed to keeping CARE as the central focus of the capture and communication of health information. Our clinical charting tool, ChartPath®, helps providers be more efficient and more effective, addressing the "Triple Aim" of better care and a better care experience at a lower cost. By leveraging the constant improvements in codified terminology, content standards, and health information exchange and interoperability infrastructure this can and will be done.