Doctors Say Narrative Missing from Proposed EHR Regulations

Physicians are pushing the federal Health & Human Services Department to include physician narratives in the proposed regulations for electronic health records. Doctors use the narrative to expand on an assessment and offer subjective and objective evaluations of a case, as well as outline the treatment plan. Some doctors use speech recognition technology for their narratives in EHR systems. The public has 60 days to comment on the HHS regulations.

The Obama administration's push for subsidized electronic health records has entered a new phase, with the public getting two months to comment on recently proposed regulations.

However, some physicians are saying that a key requirement is missing and are pressing the federal Health & Human Services Department to add it in.

The doctors are looking for a requirement that EHR software include sections for physician narrative notes, key tools that allow doctors to more clearly outline their observations, assessments and the patient's condition.

"The physician narrative is not directly addressed" in the current proposed regulations, Reid Conant, chief medical information officer at Tri-City Medical Center, in Oceanside, Calif., told eWEEK. "That narrative is equally as important-if not more important [than other aspects]-and needs to be included."

HHS on Jan. 13 published the proposed regulation in the Federal Register, including the "meaningful use" provision for EHRs that outlines the distribution of about $17 billion in federal stimulus money, with distribution set to begin in 2011. Doctors and hospitals will be eligible for the money if they use EHR technology that meets the provisions. More information can be found here.

An interim final rule that outlines certification terms and technical standards also was published. The publication of both kicked off a 60-day public comment period, and Conant and other doctors are expected to push for the inclusion of a narrative section in the regulations.

"No matter how good [EHR records] are, you'll never get the flavored nuance of the patient's [situation] if you don't have an unstructured note," said Dr. Steven Schiff, the medical director and service chief of cardiology at Orange Coast Memorial Medical Center, in Fountain Valley, Calif., in an eWEEK interview.

Nuance Communications, which makes the Dragon Medical speech recognition technology, in December published the results of a survey of 17,000 doctors, of which 94 percent said narratives were important to EHRs and 96 percent said they feared losing important patient information without them.

The EHR "meaningful uses" regulations currently outline the requirements for point-and-click capabilities, which Schiff and Conant said work well for some parts of the record, but can't replicate what is included in a narrative.

In the Nuance survey, Dr. Hal Baker, the chief medical information officer at Wellspan Health, in York, Penn., offered a comparison of a narrative note dictated with Dragon Medical and another-with the same patient and conditions-compiled through a point-and-click EHR template. The narrative note read:

""The patient is a 74-year-old female who presents with a complaint of fall, 74-year-old female presents with complaint of neck pain, headache. She states that she had mechanical fall at home where she tripped and fell downstairs, approximately 9 steps and landed on her back. She complained of shortness of breath right after the event. She noted that she had pain in her left ankle and left knee. She is not sure whether she had loss of consciousness and the patient further complains of the pain in the right wrist.""

The note from the template read:

""The occurrence was one hour prior to arrival. The course of pain is constant. Location of pain: Head leg. Location of bleeding: None. Location of laceration: None. The degree of headache is mild. The other degree of pain is moderate. The degree of bleeding is negative. Mitigating factor is negative. Immobilization no backboard in place and no cervical collar in place. Fall description tripped. Intoxication: No alcohol intoxication. Location accident occurred was home.""

About 97 percent of survey respondents said they would consider the first note more valuable in treating the parent, according to Nuance.

There could be some movement on this issue: HHS' Health IT Policy Committee met Jan. 13 to talk about the regulations, and committee members reportedly raised the lack of physician narrative as a hole that may need to be filled.

That would be good news to Conant, who is urging doctors to let HHS know the need for the narrative as a meaningful use.

"It's a critical time," said Conant, who also has created Conant and Associates, a consulting company that works with physicians and hospitals on electronic health records. "If [getting the narrative into the meaningful use list] is going to happen, if we're going to influence these regulations, the committee is going to need to hear it again and again."

Conant and Schiff both use EHR systems in their hospitals, and both use Nuance's medical speech recognition technology when creating a narrative about their cases. They said such speech recognition technology will be key as EHR systems become more commonplace, and that the accuracy of the technology has improved greatly over the past few years. Both said they're seeing gradual adoption of both EHR and speech recognition technology among doctors.

Speech recognition helps doctors give more complete narratives, and also frees up time, they said. Many doctors are not fast typists, so typing in a narrative tends to eat up time, which can result in doctors forgoing a detailed case narrative.

"Either the record is very sketchy or very, very time-consuming," Schiff said.

Other doctors will record their observations and then send the tape to a transcription service. However, as EHR systems are adopted and speech recognition improves, physicians will find the technology more useful, they said.

Nuance has become the largest of the medical speech recognition technology companies, particularly in recent years with the acquisition of competitors such as Philips Speech Recognition Systems and eScription in 2008. The $1 billion company serves about 40 percent of the largest health care facilities in the country, according to Peter Durlach, senior vice president of marketing and product strategy at Nuance Healthcare.

Nuance is actively lobbying politicians and federal regulators to include the physician's narrative in the meaningful use list, Durlach told eWEEK. The company also is working with doctors to help them get that message to HHS, he said.

For many doctors, the argument is clear: To get a more complete record into the patient file, doctors need to be able to put down their thoughts and observations, Durlach said. Five to seven years ago, most EHR systems didn't include an area for physician notes, he said. It wasn't until a couple of years ago that such capabilities were included.

"The quality of care depends on the information in the [physician's] notes," he said. "The EHRs can provide a lot of value, but there are a lot of difficult [aspects] that can affect the physician as well as the patient."