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Note Writing 101: At UPMC, Clinical Documentation Improvement Starts with Understanding the Value

November 23, 2015
by Rajiv Leventhal
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At the University of Pittsburgh Medical Center (UPMC), a 20-plus-hospital, 3,600-plus-physician health system, and renowned healthcare organization when it comes to many physician quality initiatives, innovation that involves complex detail is often the norm. But sometimes, even for the most prominent of healthcare leaders, a scaled-back, simple approach that includes a rethinking of values is necessary to make real change.

This was precisely the case for physician leaders at UPMC in regards to their plan around improving clinical documentation. As part of Healthcare Informatics’ November/December feature story on physician documentation, Senior Editor Rajiv Leventhal interviewed Vivek Reddy, M.D., CMIO of the Health Services Division at UPMC about the organization’s approach around improving note writing in the electronic health record (EHR). While that story can be read in its entirety here, HCI wanted to give its readers a more expansive view on the specifics around the work UPMC has recently done in this area. Below is a more comprehensive look at the conversation between Reddy and Leventhal.

 Editor’s note: As part of the feature, clinical leaders who were interviewed were asked their opinions on two note-writing formats within EHRs, SOAP and APSO, and which was used and preferred in their respective organizations. That sidebar piece, which includes Dr. Reddy’s response, can be read here.

What was UPMC’s strategy to improve physician documentation?

In January 2014, we started a massive initiative to look at clinical documentation improvement. We brought physicians together and asked them what their main purpose of documenting was. We quickly realized that clinicians have lost their way in the value of why they write their notes. The answers gravitated towards reasons such as billing and getting paid.

So we needed to re-focus and re-set the bar to say the reason you’re writing this note is not for billing, but to document the care you’re providing in the best and most specific way as possible. It wasn’t about putting everything in a note, or documenting these 25 things to get paid, for instance. We used that guiding principle to re-train our provider community on how to write a note and why to write a note. We had to undo the urban myth that the only thing you write notes for is to get paid. You need it to be a communication tool rather than a billing document.

Vivek Reddy, M.D.

After this was realized, how were best documentation practices developed and implemented?

We have had some good results after we got those guiding principles down. We broke down every type of note a doctor writes, including the history and physical, and the progress note, into individual sub-components. We then decided what would be the design principles about what sort of data they would automatically import in a note. What parts of a note did we want? You have structured data and unstructured data, so what would we allow to copy forward day-to-day or note-to-note? We re-configured all of our note templates to meet those standards we set.

By setting those standards, we were able to do a subjective analysis based on the length of notes, and we saw if there was cut-and-paste or copy forward taking place. We saw some good results, including at least a 33 percent reduction in length of notes just by applying these principles. The clone note problem started to go away; only sections in the note that were pulled forward from note-to-note. We also saw active note editing in those sections. Also, from content perspective, we did the subjective review, and we said, would this note communicate what is actively going on with patient and what you’re actually doing about it? So we created an arbitrary scale and saw at least a 25 percent increase on 1-10 scale of the quality of notes using that subjective toolset that we created.

What inside the parameters of the EHR could be changed and adjusted to help doctors with documentation?

EHRs have become a double-edged sword in this process. EHRs facilitate an over-reliance on putting in large sequences of text, or documenting detailed physical exams with a click, and unfortunately, that doesn’t force you down the path of why you’re documenting what you’re documenting in the chart. EHRs speed to create good billing notes but not good communication notes. They sort of messed up our center points.

[Ideally], you want EHRs that can work through documenting as a byproduct of care. Can I review data in a chart, can I tag information that I would like to include in a note, can I jot commentary about my thoughts on a certain value or results, and then can I build the note as you’re performing the work inside the EHR? That is one definite where EHRs can change game in terms of how we document. It shouldn’t be seen as a separate action or activity, but more a byproduct of what you do while taking care of a patient.

Is note dictation commonplace at UPMC?