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Should Physician Notes Be Turned Upside-Down? Brian Patty, M.D., Has Some Thoughts

May 8, 2014
by Mark Hagland
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Brian Patty, CMIO at HealthEast in St. Paul, has ideas about physician documentation reform

Brian Patty, M.D., vice president and CMIO at the four-hospital, 650-bed HealthEast Health System, based in St. Paul, Minn., is one of many CMIOs around the U.S. working to improve physician documentation in patient care organizations, for the sake of everyone—physicians, nurses, other clinicians, administrators, and above all, patients. Patty was one of the CMIOs interviewed by HCI Editor-in-Chief Mark Hagland for the magazine’s April-May cover story on physician documentation reform.

Patty has been in the trenches working with his colleagues at HealthEast to improve the way in which physicians document; indeed, he is leading an effort to improve documentation now, as his organization implements a new electronic health record (EHR) from the Verona, Wis.-based Epic Systems Corporation. Below are excerpts from Mark Hagland’s interview with Dr. Patty earlier this spring.

What should happen when it comes to physician documentation reform?

There’s a lot that we can do in how we structure notes in the EHR; it’s all too easy to pull a ton of information into the daily progress note, and a lot of that is not needed. Just training physicians to structure their notes to be more succinct helps. What I really tell physicians is, if your note isn’t viewable on a single screen. We’re trying to get them to provide more pertinent information; and we spend a lot of time designing our notes.

Brian Patty, M.D.

What are the elements that make for a better note?

When someone’s reading a note, what they really want to get at is, what did you find and what are you going to do about it? That’s the assessment, what you found, and the plan—what you’re going to do about it. And so if you switch to an APSO format [“Assessment, Plan, Subjective,” Objective, versus the traditional “SOAP,” or “Subjective, Objective, Assessment, Plan” format that the vast majority of doctors were taught in medical school], that gets that information to the top of the note. It tees the information up; it’s like reading the executive summary in a magazine article first, and then choosing what I want to read in the story. So you’re essentially teeing up the meat of the document first.

There are also certain things we can do to structure documents to make them more succinct. In an ICU patient, for example, you could structure the document to pull in the last 24 hours' worth of laboratory values; and that could amount to several pages. So the solution there is teaching physicians to pull in just the labs they found pertinent to their note today—to teach them the shortcuts to pull in just those lab values, along with a note saying, the bulk of the lab values are available, with the availability of those other lab values just a click away. And quite frankly when you’re in the lab section, you can trend stuff and do a lot of things you can’t do in the note. So just doing simple stuff like that. Often, if a patient is set for a radiologic study, you could end up pulling in the entire radiologist’s report, but instead, you could choose just to show the conclusion.

What I really tell physicians is, look at your note; if your note isn’t viewable on a single screen, it’s probably just too big, so get them to be pertinent with their information. And we spend a lot of time designing our notes. We’re currently installing Epic [with a scheduled go-live date of June 1], so we’re looking at the design of how we document in Epic, to have physicians documenting really what’s needed to get the story across; yes, you need to capture all the information for meaningful use and stuff, but you don’t necessarily need to pull that into the daily progress note.

The other thing that you can do is to do what’s called problem-oriented charting, which really gets to an assessment and plan for each problem a patient times. Oftentimes, especially in the hospital, the patient has multiple issues that you’re dealing with; and having to wade through a long note can be very difficult. So saying, here’s problem number one, and here’s my assessment and plan for that problem; and here’s problem two, and here’s my assessment and plan for that problem, that makes the note a lot more readable.

How should CMIOs position themselves for leadership in this area?

We’re really there to help the organization have a clinically relevant EMR; and so whether it be physician documentation, physician order sets, nursing documentation, nursing care plans, whatever it is, we should be helping the organization design an EHR that’s clinical relevant, so that we’re taking care of our patients and documenting that care.

Were things getting out of control in healthcare before documentation reform began to take off?

Yes; basically, just because I can pull all of this information automatically into a note doesn’t mean I should; and we really need to do the hard work of asking, what’s clinically relevant to this patient, today? And answering that. It’s very easy to create a note that pulls everything into itself; but in designing notes upfront, and also in documenting to focus on what’s clinically relevant for this patient, is important. And I really do find it interesting, as we were looking towards documenting for ICD-10, most of the time, if you’re creating a good note, most of what needs to be communicated in ICD-10—laterality, severity, chronicity, those are all things that you should be communicating anyway.