Douglas Johnston, M.D., a cardiovascular surgeon, and director of the length-of-stay and throughput initiatives taking place at the Cardiovascular Institute, a division of the Cleveland Clinic Health System, Cleveland Oh., is a practicing surgeon who is very supportive of the medical documentation improvement efforts taking place at Cleveland Clinic. He has been working closely with William Morris, M.D., vice chairman of clinical systems, and a practicing hospitalist in the organization, and with Susan Belley, manager of coding and documentation improvement, on a project to improve the quality of physician documentation among doctors practicing in the Cardiovascular Institute there. A description of their work can be found in the May cover story of Healthcare Informatics.
Johnston spoke recently with HCI Editor-in-Chief Mark Hagland regarding his perspectives on the challenges of making physician documentation work for everyone. Below are excerpts from that interview.
How do you see the tension between free-text and structured documentation?
The challenge is finding ways, I think to think outside the traditional paradigm; and there’s a cultural barrier in that we are all trained as physicians and other providers to believe that documentation is a matter of putting certain verbiage down on paper, whether physical or virtual, and that that is an endpoint for the encounter, and that that is a narrative. It’s not a concept-oriented thinking, it’s a narrative-oriented thinking.
And actually, that’s not the way we think about patients. We end up synthesizing what’s really a very fluid process, regarding patient problems; and I think we already lose something right off. There’s a certain element of information that works best in free-text: Mrs. Jones is a very elderly lady, more frail than appears, etc. And, this [optimizing physician documentation] is more difficult because of that.
Douglas Johnston, M.D.
On the other hand, everything we’re measured on is in terms of diagnoses; and if we can’t find an accurate way to produce an accurate list of diagnoses, we’re thrown into a harsh light. And come to think of it, most of our encounters with patients are longitudinal.
So we’re thinking, what did I think was wrong with the patient before? What’s changed? Etc. And we don’t currently have the tools we need; right now, we produce a note. And I think that’s actually detrimental to the thinking process. What we really want is a heads-up, fighter-pilot view. And we’re certainly not there yet. But the first step of the way is to ask, what’s essential that we need to know? Figure out what’s wrong and what the essential interventions are. So if we think of documentation within that paradigm, it will work better.
So one should think about problem lists first?
Yes, that’s what we’ve set up here. We think it makes most sense in terms of serving patients. But we certainly have to meet external requirements. So phase one is providing the metrics and tools to support problem-oriented documentation—help facilitate problem lists and still facilitate a note for billing and regulatory purposes. But that note can be structured around the problems first—make the notes in order of APSO—assessment, plan, subjective, objective, instead of subjective, objective, assessment, plan (SOAP) [the traditional sequencing of note-making among physicians]. SOAP is about constructing a note around the way you interact with the patient; I call it the Florence Nightingale approach. Meet with the patient, get their story, construct a narrative and plan. But in reality, if we know the patient is a diabetic, we don’t necessarily start at zero. What’s important is that you can create a note that will immediately help your next colleague down the line.
The other thing we did was to structure it so that the problem list pulls automatically into the note. So that all the thinking work in terms of taking care of the patient is done within the problem list. And we’ve structured the process of rounds around the problem list. So when the residents and mid-level providers—NPs and PAs—do rounds, they open the notes, and they first get the problem lists.
Today, we need to order an echo—so the work structure is all around running through the problems. And as they wheel the rolling computer in there, they say, Mrs. Jones, this is what we’re going to do with you today. So the problem list also becomes the plan of care, and everything becomes transparent in terms of what we’re doing.