An Industry-Leading Innovation in Physician Documentation

Not really. It practice, it just hasn’t worked out as well as expected. So the APSO has been very successful here, related to finding things within the notes. And second, we’ve implemented the semantic search feature, and basically, the ability to basically “Google” the chart, has been well-received.

Jin Hahn, M.D.: As Chris mentioned, one of the issues is that electronic notes are not as easy to cruise over as paper notes. So one of the things that we did was to create the APSO note. And that makes it easy to see things at the top, without having to scroll all the way down to the bottom of the record; the other thing was the way we ordered the folders. You can go to the clinical documents and see them, and there’s a hierarchy of folders with different types of notes. And we use a special script so that the names of the specialties and note types are [visually distinguished], whether it’s a consult note, a progress note, or an admission note. So, for example, under each folder, you might have a specialty that’s mentioned, and you can quickly find if it’s a cardiology note or a neurology note, etc.

Jin Hahn, M.D.

What have been the biggest lessons learned so far, and what would your advice be for other clinical informatics leaders, in this area?

Hahn: I would say that, given that physicians do prefer more of a free-text format, and they’re hindered by having to use multiple clicks, we’ve developed a system using a one-click method, which takes them to specialty note tabs; and they can continue to work on that note during rounds, and capture rounds, and then continue that note. So this is designed to fit within the[physicians’] workflow, and also allow them to use free text, as well as bringing in other data as they need.

Longhurst: Yes, I would reflect what Jin said. If you take a step back and realize what’s happened here, our vendor, Cerner, sank tons of money into developing this tool called PowerNotes, and we basically said, that tool is not satisfactory, and here’s a tool basically built on Microsoft Word, and this works better. So we’re basically saying that your developed tool doesn’t work so well. And literally, nobody has done this in Cerner, in the way we’ve rolled it out, though we were certainly inspired by colleagues from Los Angeles Children’s and Boston Children’s Hospitals.

I think this illustrates that CMIOs and other medical informaticists will have more say now in critical areas such as physician documentation, now that they have more skills and development.

Longhurst: I think that’s a great point. The existing tools are not necessarily always the best. My concern is that the vendors are reallocating resources to meaningful use and regulatory requirements, and have washed their hands of physician documentation, while the tools are just not there yet.

Hahn: AMDIS [the Association of Medical Directors of Information Systems] is trying to write a white paper on reworking clinical documentation. While that is a great paper and project, there are still a lot of unintended problems and consequences, such as the copy-forward problem, that still exist. Because you have errors of commission and omission in that context. And we’re trying to help vendors help us in that area. The same thing is true in terms of the note-forward format, and the problem with scrolling. So those are some of the issues we’d like vendors to tackle.

What would your advice be for CMIOs and other medical informaticists in all this?

Longhurst: We’re certainly not the first to document an ROI on this, but we did show a massive reduction in related transcription costs; so taking an approach that was both fiscal as well as focusing on clinician workflow benefits was very well-received. In addition, I would endorse what Jin said, that informaticists should consider that collecting data in a certain way might not necessarily be the best thing to do in terms of supporting clinicians’ and patients’ needs.

Hahn: Also, for the most part here, the increase in time required to document using this format, was mostly in the ICU, but not the on the general acute-care floors, where most notes are created.