Physician documentation in the patient record has long served multiple purposes, from core clinician-to-clinician communication, to billing requirements, to data analysis tasks. Now with the advancing progress of the meaningful use process under the federal Health Information Technology for Economic and Clinical Health (HITECH) Act, even more elements are being added to the demands on M.D. documentation. What kinds of strategies are the leaders of pioneering organizations coming up with that might serve as models for their peers across the industry?
Physician notes as M.D. to M.D. communication versus physician notes as data reporting/analysis source
M.D. documentation as physician tool versus M.D. documentation as facilitator of an electronic medical record system
M.D. documentation related to ordering in the CPOE versus M.D. documentation as notation (workflow)
For CIOs and other healthcare IT leaders-but most especially for CMIOs-the issues around physician documentation in the patient record have long posed major challenges. After all, what is physician documentation really for? In point of fact, the bundle of tasks under the umbrella called physician documentation serves many different purposes and requirements, from the most basic, including for individual physicians to be able to recall details about their patients and for them to be able to pass on that information to other physicians and clinicians, to a host of other purposes, including billing, medical-legal compliance, and clinical data analysis.
Now, as the quality data reporting requirements embedded in the meaningful use process under the HITECH Act add yet another layer of complexity, that new element in the mix is forcing healthcare IT leaders to go back to the basics in order to make physician documentation better for everyone-especially for the physicians themselves. All the stakeholders around the table-including clinicians, clinician informaticists, IT executives, health information management professionals, and financial and administrative managers-can agree on at least one thing: the process of optimizing physician documentation in the electronic health record (EHR), whether in the inpatient or outpatient spheres, is complex and challenging.
And underlying and cross-hatching the challenges over the multi-purpose nature of this set of tasks is the perpetual, dynamic tension between free-text and structured documentation in terms of how medical documentation is organized and presented to end-users. What's more, the very organization of the EHR, in which ordering is artificially separated from notating as a completely separate task, adds to the difficulty of improving physicians' workflow, and thus hampers adoption. So how will this all work out?
Care Management Focus: How One Medical Group Eased the Documentation Transition for its M.D.s
For James L. Holly, M.D., CEO of the 22-physician group Southeast Texas Medical Associates, in Beaumont, Texas, the key to solving the physician documentation side in the medical group context lies in embracing the very broadest goals of care management, to motivate doctors forward. Resolving the contradictions within physician documentation processes “isn't as big a problem on the outpatient side as it is on the inpatient side,” Holly says. “However, we have designed structured data sets for the hospital that work beautifully to provide a structured data set that works magnificently. And the most important document on the inpatient side is not the history and physical or the daily progress notes, but the discharge summary.
“So we now call it the hospital care summary and the post-hospital plan of care treatment plan,” Holly says. “That's the baton we hand off to the patient, with reconciled medication lists, follow-up care information with the provider's information; it includes a follow-up call scheduled for the next day, and a number of other things. So I think the physician documentation problem is solvable, it just takes a little more creativity and time to solve the problem.” That, and very importantly, of course, the fact that he and his colleagues are moving forward under a banner of continuous performance improvement and care quality optimization.
STRATEGIZING AROUND STRUCTURES
Nationwide, healthcare IT leaders at pioneering patient care organizations are helping their colleagues to think through this Gordian knot of considerations, and coming up with a variety of strategies. For example:
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