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Notes on Note Bloat: CIO/CMIO George Reynolds, M.D. Offers His Perspectives

May 20, 2014
by Mark Hagland
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CIO and CMIO George Reynolds, M.D. of Omaha Children's shares lessons learned around physician documentation reform

George Reynolds, M.D., CIO and CMIO at Children’s Hospital and Medical Center in Omaha, is among the group of CMIOs and CIOs working to reform physician documentation in patient care organizations. Given that Dr. Reynolds has been holding down both the CIO and CMIO roles at Omaha Children’s for years, he has exceptionally informed perspectives on issues around “note bloat,” documentation for patient care and analytics purposes, and so on.

In the case of Children’s of Omaha, inpatient electronic documentation only went live last summer, though it had been live for several years on the outpatient side. Dr. Reynolds was one of several CMIOs interviewed by HCI Editor-in-Chief Mark Hagland for the magazine’s April-May cover story on physician documentation reform. Below are excerpts from their interview earlier this spring.

Do you agree that physician note-writing needs to be reformed within the electronic health record?

The EHR turns physician note-writing on its head. In the paper world, less was more, and you’d get the classic surgeon note that said, ‘Patient doing well, continue with above,’ and really, though billing concerns might drive more than that, the pressures of time made people perhaps too succinct. The EHR allows you to blow in all sorts of extraneous content, and obviously, with copy-and-paste and copy-and-forward, you can insert all sorts of unnecessary content. In other words, note bloat exists.

George Reynolds, M.D.

In my interview with Brian Patty, M.D. of the HealthEast Health System, he told me that he has pushed practicing physicians to shift from the “SOAP” format to the “APSO” format, with “SOAP” standing for “subjective, objective, assessment, plan,” in the traditional documentation format that physicians have historically learned. You’ve done that also at Children’s of Omaha, correct?

We’ve been live on Epic on the ambulatory side for years, but only went live with Epic, and with electronic physician documentation, last summer. We did go with the APSO format as a standard; now that doesn’t eliminate note bloat;  it just puts the bloat at the bottom of the note. But we eliminated thousands of smart links—and there are literally 5,000 of them that you can pick from; and we picked a kind of top 40, and taught the top 40, and taught people to use smart phrases using smart links.

What have been some of the biggest learnings from going through this optimization and training process?

People have some ingrained beliefs about billing requirements and documentation requirements, so there’s an education process—not just for physicians, but for coders, as well. And I just had this conversation with a doc, and said, you know, putting in three days’ worth of chemistry results and so on—doesn’t do anything. Commenting on the results—addressing abnormal labs, saying, I’m going to address the abnormal potassium—that’s what’s important. And there’s one group I can’t convince, and no matter what I say, they still want to put in a bunch of junk. But Epic has a new feature that will allow you to automatically collapse sections, so that a section might be in the note, but it doesn’t appear on the screen. But in general, we’ve been pretty successful, because a lot of the notes are for residents, and residents are here to learn; and most of them get smarter about it as they go along.

What should the CMIO-CIO discussion be like around this, and how can CMIOs show leadership? You really have a uniquely important perspective on this, if I may say so.

It’s a critical dialogue, and it’s going to be individual to the people and institution; but there has to be trust that each has the other’s back, and they understand each other. The typical CIO is juggling the technology and infrastructure and budget, but he or she is in healthcare because they want to help the patient, and they’re looking for advice on how to prioritize the ten thousand things being asked of them, because, absent a critical discussion with a CMIO one can trust, decisions get made based on who screams the loudest or who has the most clout. So it’s the CMIO’s role to help the CIO understand what investments will result in the most value, and it’s the CIO’s role to continue to hold the CMIO accountable for that guidance. So you need to understand each other’s pain, and it’s about that learning environment between the two.