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An Industry-Leading Innovation in Physician Documentation

June 10, 2012
by Mark Hagland
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Medical informaticists at California’s Lucile Packard Children’s Hospital achieve a breakthrough in EHR usability for doctors

One of the thornier, more complex challenges in the ongoing evolution of electronic health records (EHRs) and computerized physician order entry (CPOE) systems has been the ongoing tension between free-text documentation and drop-down menu-based documentation choices for physicians. In the paper-based world, physicians have traditionally followed the “SOAP”—Subjective, Objective, Assessment, Plan—format for creating progress notes, with subjective or historical information presented first, followed by objective findings (physical exams, lab results), and concluding with the assessment and plan. With the emergence of the EHR, however, and the ability to electronically append very large amounts of information to any document or set of documents, many physicians have found the traditional “SOAP” format to have become unmanageable, and have found a different sequence, known as “APSO” (Assessment, Plan, Subjective, Objective) to be preferable in an electronic setting, as the APSO approach brings forward the assessment and plan, often the elements the busy clinician is looking for first. The challenge becomes particularly acute in the context of what’s called the “copy-forward” problem, in which successive physicians continue to add to a core set of documentation, until the electronic information on a particular patient becomes wildly unwieldy and nearly impossible to parse without a very intensive investment of time on the part of subsequent physicians.

In an article entitled “Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital,” which was published in the journal Applied Clinical Informatics and appeared online at the beginning of May, Jin Hahn, M.D., Christopher Longhurst, M.D., and three other physician colleagues at Lucile Packard Children’s Hospital (LPCH), Palo Alto, Calif., described a unique approach to resolving the free-text-versus-dropdown tension. As the authors note in the summary paragraph to their article, “Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children’s Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process,” they explain.

As the authors note later in their article, “The rollout [of the hospital’s physician documentation capability] involving 46 inpatient services (31 medical and 15 surgical) was completed in 12 months. A total of 254 specialized note templates were created for these services. In addition,” they note, “181 system-wide auto-text shortcut macros were created that brought in vitals, intake and output, medications, laboratories, and teaching physician attestations. As a result of this effort and the previous CPOE and nursing documentation implementation, the entire hospital is now considered to be level 6 on the HIMSS EMR Adoption Model.”

Dr. Hahn, the hospital’s medical director of clinical informatics, and Dr. Longhurst, its CMIO, spoke recently with HCI Editor-in-Chief Mark Hagland regarding the process of physician documentation implementation they pursued at LPCH, and the lessons learned so far. Below are excerpts from that interview.

What were the most important elements for you in pursuing your innovation around physician documentation?

Christopher Longhurst, M.D.: There were three takeaway points for me in terms of what we accomplished. First, there’s this eternal struggle between free-text narrative versus structured data. And for many years, the informatics community weighed in on the side of structured data. The concept was, create structured data for outcomes, reporting, analytics, and decision support. But while the informatics community thought this was a great idea in theory, the end-user clinicians didn’t. So the first decision we described in the paper was that we rolled out a very free-text-narrative approach to physician documentation, and we mitigated the issue of not creating structured data, by occasionally creating forms when appropriate. So that really contributed to the rapid adoption.

Christopher Longhurst, M.D.

The second point that I would make that was well-described and really important in the article, is that copy-and-paste is a problem with every implementation of physician documentation. I think this is a really well-described approach to trying to mitigate that. It wasn’t perfect by any stretch, but the carry-forward boxes that Jin described helped bring forward aspects of the note that improve workflow, but because you’re already carrying forward a piece of the note, you’re de-cluttering things.

And the third thing I think that’s interesting is the search for data in the electronic health record. How do you find everything when you have all these notes online, not just the physician’s notes, but the nurse’s, and the chaplain’s, etc.? This is the first example of the APSO note, which describes a sort of bastardization of the SOAP note. So you actually put your assessment and plan at the top of the note, which is what doctors do anyway.

Was the SOAP note an artifact of the paper-based world?