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The Doc's Doc-Part II

June 5, 2011
by Joe Bormel, M.D.
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The transition from hybrid paper to electronic Physician Documentation has become messy in the age of MU.  What do we really need?

In Part I of this blog, I began by noting how messy the transition to electronic Physician Documentation has become. The constructive, intelligent comments I received from readers thus far have been greatly appreciated. If you haven’t read them all, I invite you to do so. They are of considerable value.
As the Chief Medical Officer of a software and services provider, I work with a team of very smart people including fellow staff members, business and hospital partners. This has given me the opportunity to view system development from a variety of perspectives. But our common goal has always been to provide systems that improve the quality of patient care, help health systems respond to ongoing industry challenges, and now, help clients achieve Meaningful Use, which will underscore the success of our efforts. Physician Documentation plays a critical role in the Meaningful Use process.

In his comment to Part I of this blog, Dr. Howard Strasberg noted that he and his team have been using transformative approaches to documentation solutions that were not possible even five years ago. This is a fine example of taking what was, replicating it for study, adding a healthy dose of innovation, knowing that what was would not yield the desired results, and transforming that innovation into an effective solution. The process is evolving, and from my experience we are making progress. So let’s explore some plausible alternatives that could improve the current nature of Physician Documentation and increase the speed of its evolution.

A group of brilliant physicians and developers, delivering solutions on modern platforms, have not been “RESTing.” To understand this term requires more space than I have here, so I suggest you visit this link, which addresses modular EHR technology. I think you’ll find it interesting and helpful. As you’ll see, this technology is far from a complete transformation, but improvements like it, and the advances in clinical decision support architecture I see continuously in my work, are very promising.

The reality of such approaches means that, too often, architectural bottlenecks and workflow disconnects don’t bridge the gap from Innovate to Transform. In much the same way, a decade ago smart people thought they could interface disparate pharmacy, nursing and physician platforms. But achieving tight integration with wrapped subsystems ultimately never worked at scale in the real world.

If We Know Which Notes are Never Read, Do Our Requirements and Design Process Change?

In a recent article from Columbia University, “Use of Electronic Clinical Documentation: Time Spent and Team Interactions,” researchers Hripcsak et al drew a couple of conclusions that struck me as important.
 

First, care providers spend a significant amount of time viewing and authoring notes. But some notes are never read, and the rates of usage vary significantly by author and viewer. Additionally, while the rate of viewing a note drops quickly with its age, even after two years some inpatient notes are still viewed.

Second, a lot of writing, whether it's an admission note, a daily progress note, or ambulatory visit serve the purpose of helping the author organize and distill their thoughts. If that's part of the principle value of Physician Documentation, shouldn't the tool specifically facilitate that kind of organization in the clinical domain?

So What Tools Should We Deliver?

The Columbia researchers make an interesting point that should encourage us to rethink the functionality of Physician Documentation tools so they better address the priorities required to make them effective. Based upon this research, much of the value electronic Physician Documentation can provide should be derived from the capability to streamline the organization and review a note during its construction.

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Dr. Joe,
Great story...couldn't have said it better. I just hope we don't get too lost in all the structure and lose site of 'hope'.
Frank

Dr. Bormel,
Part II of your series has proved to be a very good wrap-up, not only for presenting the challenges facing effective physician documentation, but for posing logical methods for significant improvement. It was worth waiting for.

From my point-of-view, the vendors will never directly collaborate to find common HCIT solutions. Putting potential legal issues aside, vendors seek to market systems based upon their unique approach to solve complex problems that help their customers attain reasonable goals. Certainly, cost and related factors are a part of the decision making mix by providers. But it really comes down to reputation, ala references, the vendor's long-term prospects to remain in the marketplace, and it's ability to listen to its customers to develop pertinent system enhancements, while ensuring the provider organization will remain in compliance at every level.

In one sense, vendor collaboration does exist in a tangential manner. What drives such things as system interoperability are the common demands of customer providers and government regulation. CMS and The Joint Commission, for example, are really "turning the screws" in terms of standards for both systems and quality care. In turn, hospitals and other providers are demanding their vendors develop systems that conform to these standards to keep them competitive and financially viable.

My view is this is a good thing, because just as trying to mix and match many disparate best-of-breed applications to build an end-to-end EMR failed in the past, so we must get passed single vendor proprietary standalone systems today. To paraphrase an old saying, "No system is an island." That simply will not work moving forward. Effective physician documentation is a critical element of a successful EMR, as well as HIEs, etc.

I fully realize that I have oversimplified the process that will drive what will hopefully be a solution. But the fact remains, no healthcare provider at any level should be able to state, "We provide the best care anywhere." Instead, we should all, vendors and providers alike, be working toward the goal of being able to say, on a nationwide basis, "We provide the best care everywhere." We can do no less.

Doc Benjamin

Joe Bormel,

Thank you for this wonderful post! You have many different ideas in here, all compelling and provocative.

I would like to focus on two elements that struck me particularly. One was around your mention of ACOs. While I agree with you 100% that the emergence of ACO structures will provide a wonderful opportunity to rethink the physician documentation process, I also believe that no innovation will take place by chance or without considerable thought and thoughtfulness. I had not considered the challenges related to physician documentation that tie into ACO operations, but I can see considerable complications in this area once I begin to ponder them. Yet another area where we need brilliant, focused minds honing in on the healthcare system's challenges!

Meanwhile, I also believe that the vendors really, REALLY need to focus far more, and far more effectively, on physician documentation both generally and with regard to numerous specific issues, than they have to date. While on the one hand, it's great to have a broadly competitive EHR vendor market, I would add that in this particular context, one can see the weakness of a competition-based vendor market system.

It really would be great for the vendors (if this were legally possible, which it isn't!) to get together and develop some kind of common approach to physician documentation that would considerably improve processes in our industry. Alas, I know such a development is impossible.

The best we can hope for is that a few vendors come up with such brilliant innovations that everyone else moves rapidly to copy their core concepts. Again, to be clear, I strongly support the idea of market competition in most contexts but here is an area where it's clear that there is some weakness for us all as well.

Thank you again for this fantastic contribution to our industry-wide discussion on a topic of critical importance to everyone!

Mark

Thanks Frank. No quibble at all. This is a first class, multi-stakeholder improvement opportunity.

Your reference back to academics, med school and training reminded me about the critical role of hope in care delivery. A world renown, accomplished and caring physician friend, Jeff Guterman, told this story:


A medical student seeing patients under supervision at a teaching clinic proudly came in to report to Jeff on the patient he had just seen. The student said, "I disabused the patient of the notion that the tuna fish (hypothetical for this story) was remarkably effective at reducing their intractable chronic pain." Jeff said to the student, do you have an effective treatment for their pain? "No" was the response. "So you just took relief and hope away from the patient?" "I guess so. Not so smart, was it?" "No. If something works for a patient and doesn't cause harm, smile and reassure that they should probably keep doing it."


Where does "Hope" fit in evidence-based medicine, quality measures, patient instructions, problem-lists, and the rest of MU? They're not incompatible, but hope and dignity-related acts are different and they are an important part of care.  Structure, codification, templates, order sets, and clinical decision support are useful tools in the context of the right problem.  Softer documentation has it's role, as do kindness and humility.  Should the problem list contain "Placebo-controlled Sciatica"?  I'm sure we have a better ICD-10 code that obfuscates that one!

We all hope the electronic health records wont degrade the important human caring captured in the story.

Dr. Joe,
As Mark said, you hit a number of very good points, and the responders to. But I have a quibble with the position that it really is a 'vendor' problem — or a vendor solution.

Take a step back. Where do vendors get guidance on the framework, and structure of care documentation? Of course, from doctors. Now where do the doctors get the same from? From their medical school. I am not a physician, but from my experience in working with many in different settings where you went to Med School and interned are the primary drivers in how you do it today. I have my doubts that we will ever get to a one standardized form of care documentation, maybe a general framework yes, but not too far beyond that. To my mind the practice of cognitive medicine has a whole lot of judgment in it and what one doc focuses on may not be what the next cares to see. Depends where he/she was trained and who trained them.

If there is going to be a more defined structure for process and content it has to start in Med School. Computer systems design thrives on structure and definition, I am sure the vendors would love to see more.

Lastly one of the great ironies I see in all this is that over the years I have heard repeatedly from academic docs that they could make great strides in research if only the clinical docs would structure and codify all that bedside information. I fully agree. But who trained the clinical docs to do it that way? The academic faculty!

Doc Benjamin,
Thank you for your brilliant comments. We really are moving from the horse and buggy era of healthcare, through the age of many automotive vendors, and recently into ONE definition of certification and meaningful use. As you beautifully point out, it reframes healthcare delivery and the enabling information technology.

We should all ponder "We provide the best care everywhere." Of course, depending on which word you emphasize, the meaning changes!

Mark Hagland,

Thanks for your comment, and, again for your original Balancing Act article last month. My friends leading the providers charge for the ACO ambition and PcMH always focus on addressing the care gaps today, often associated with inadequate handoffs. There's lots of great coverage of the solutions in Healthcare Informatics, most recently from Dr Holly of SETMI and elaboration of the "baton." Building these handoffs into the electronic physician documentation as required mini use cases will emerge as a design requirement.

You are quite correct. Vendors are critical to delivering better, more integrated physician documentation. My only qualification is that the critical learning and design improvement always requires close collaboration with leaders at provider organizations.

Joe

great story....

Thanks Mary James.

This has been a fascinating year in the evolution of physician documentation. Reasonable efforts to encourage strict compliance with SNOMED CT (an MU2 thing) in the problem list resulted in a backward compatibility nightmare for those early adopters that started years before ARRA/HITECH. And, we all discovered that the problem list was used as a trustable way to assure that certain documentation was seen, even if it wasn't exactly a problem.

We learned a lesson recently retold by James Gleick here (http://www.amazon.com/The-Information-History-Theory-Flood/dp/1400096235/ref=sr_1_1?ie=UTF8&qid=1408584046&sr=8-1&keywords=gleick+the+information) in a book titled "The Information: A History, A Theory, A Flood." The lesson is that a certain degree of ambiguity and redundancy is built into and required for language, just as there is a requirement for incompleteness in mathematical systems, and uncertainty in quantum physics (Heisenberg).

Our expectations (and policies around) provider documentation should be better informed by scientists who study science and history. Gleick's book wasn't out when I wrote the post. Consider it required reading now for those interested in a great set of stories!

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Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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