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Of Physician Documentation--And Disaster Recovery

July 13, 2013
by Mark Hagland
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Brian Yeaman, M.D., CMIO of Norman Regional Health System, shares important thoughts about physician documentation issues—and disaster-recovery lessons learned

In early June, HCI Editor-in-Chief Mark Hagland interviewed Brian Yeaman, M.D., of the Norman Regional Health System in Norman, Oklahoma. Yeaman has been with the health system since 2008, and has been CMIO there since 2009 (while he continues to practice part-time as a family physician and as a hospitalist). The planned subject of the interview was the challenges and opportunities inherent in physician documentation these days, including the role of speech recognition technologies in optimization the physician documentation process (the Norman Regional Health System has been using the suite of speech recognition solutions from the Burlington, Mass.-based Nuance Communications).

But, given the devastation wreaked upon the local area by the May 20, Moore tornado—which destroyed the Norman Regional Health System’s Moore facility—Yeaman and Hagland naturally spoke first of the tornado experience, its aftermath, and lessons learned from that disaster. Below are excerpts from their interview.

Moore Medical Center, before and after the May 20 tornado

Before we converse about physician documentation issues, how are you and your colleagues doing, following the tornado of May 20?

Moore Medical Center was our hospital; we had three facilities, including the Moore facility, which was completely destroyed. I happened to be the hospitalist on call that night. All the electronics and communications went out. I was in our clinic in Norman, and I automatically went to the main campus.

So the Moore facility is a complete and total loss. But the way our team came together was amazing.  Our director of radiology there was shooting films at the time of the tornado. And as CMIO, I was watching everyone zoom around with COWs [computers on wheels]. We saw 134 patients in three hours that day. And we had just launched Nuance in the ER about two weeks before. The doctors were using the EHR and using Nuance. So what happened was that we had 98 employees who fully or partially lost their homes, and about 50 who lost their cars.

And actually, the ONC [the federal Office of the National Coordinator for Health Information Technology] sent out a documentary film crew the week after and followed us around, and I walked them through some of the storm damage at Moore Medical Center, which was a total loss. And we had a lady who was a “9” in labor [9 centimeters dilated] at Moore; but we transferred the patients to Norman, and never missed a beat on them.

Brian Yeaman, M.D.

What happened to that lady?

It’s incredible. L&D [Labor and Delivery] at Moore Medical center—they moved them all down to the first floor and the inner corridor. The woman who was a 9, they moved into a c-section room on the second floor. They had the woman on a gurney, and the nurses were holding onto her—her labor arrested, we got her into an ambulance, and got her down to our neighboring hospital in Norman, and she delivered in Norman.

Were there any lessons learned from the terrible experience of the Moore tornado?

I mean this very generally, and this was my point to Farzad [Mostashari, M.D., national coordinator for health information technology] when I talked to him about it afterwards, because they called us to check in on us—we were an early adopter for meaningful use, and we moved to VMWare [the core cloud computing solution from the Palo Alto, Calif.-based VMware, Inc.] ,and did a lot of zero-client; and because of a lot of redundancy with our servers, we didn’t miss a bit. And we have a very robust health information exchange. Our arrangement was that we had three campuses running off one central database, with one redundant location. But there’s also some serious, tangible value to what we’re doing with meaningful use stages 1 and 2, and in terms of health information exchange. And because of that infrastructure, we were able to shine through. And I think that’s why Farzad sent a camera crew down; I imagine that the camera crew was as much for the President and Congress as anyone else.

Do you have anyone reporting to you as CMIO?

There are a lot of dotted lines, but no one who reports to me formally. We have 26 people in our IT department and eight clinician analysts; and in the Norman Physician Organization, there are another three analysts there. I lead strategy for that. The analysts are full-time, most are RNs.

How would you characterize the state of physician documentation right now?

Right now, here, we live in this world that remains a mix of electronic and paper notes. And on average, you can’t read half of the paper note. And the part you really need to evaluate from the consulting or attending physician, you can’t read; so that part speaks for itself. We have gone live with physician documentation, but there’s still a fragment who are documenting partly on paper; in September, we end all that. At least half of our notes on the inpatient side are being done electronically, and half aren’t; we’re getting ready to do a big bang—we’re “partially pregnant” for CPOE [computerized physician order entry] and physician documentation, and when we flip the switch, we’re going to go full-out.

We’re getting ready for Stage 2 of meaningful use; Stage 1 required only 20 percent of your notes to be electronic. So with traditional dictation, the turnaround rate is fairly slow, and the error rate is fairly high. The docs who are typing their notes—I think that is helpful, since I can see those notes in real time and anywhere. It’s frustrating, to some extent, because some of them don’t write a significant amount—they’re using templates, and the notes can be somewhat cookie-cutter, so you’re losing some of the patient’s story—you’re seeing aspiration pneumonia, for instance, and you’ve just initiated treatment with two antibiotics.

And a lot of times, traditionally, you’d elucidate your thought process, and those types of subtleties tend to go away when the docs type in their notes, because of the time involved. So some of the story is lost and some of the artfulness of the notes is lost. So with PowerMike with Dragon in Nuance, the docs are still using the templates, and that supports meaningful use; but the nice thing is that the story and the subjective is better, because there’s more narrative-type text. And then the physicians put in their thought process more, because they’re speaking.

The deeper challenge in this is that we’re dealing with a culture change; we’re asking the physicians to change what they’ve always done. And physician documentation is one of the hardest elements, because a lot of them can’t type. So the ER docs were hesitant at first, but they’ve liked it. I’ve had one doc who’s chronically on suspension because of not getting his notes done, but on Nuance now, it’s not been a problem. And this will save us a million dollars a year; we see 100,000 visits a year to our ER. We had ERs in all three; the main ER is on our main campus, the Porter Campus.

So it’s not just about the ability to type, but how many tasks the doctors need to accomplish, that makes speech recognition necessary, then, correct right?

Yes, it’s a combination of things; you’re dealing with two or three patients on the same floor, dealing with nurses, trying to take notes, trying to enter orders, all at once. And the note has just become such a laborious thing—and frankly, the note is primarily documentation for Medicare, to prove we’re not committing fraud; and for medical-legal purposes for the attorneys; and with the templates, it becomes very routinized, and what the doctors are trying to input themselves becomes minimized; and with having to do so many things at once, that’s hard. The older physicians will certainly embrace speech recognition, because they’re not having to type. But for the younger physicians, it’s about better workflow. Me personally, I can type like the wind; but I was starting to get some carpal tunnel syndrome. Two hundred e-mails a day, and constantly typing in notes; that’s a real challenge. So I absolutely love our speech recognition solution, and my nurse loves it, because when I do a telephone message back, my thoughts are in there. And the nurse practitioners like it, because they get more of the subtlety.

So they’re reading these notes that you had automatically gotten into the note via the speech recognition solution?

Yes, and that’s nice, because let’s say they’ve got a new penicillin allergy; I’ve dropped that into the note;  and if they’re allergic to sulfa, I’m going to start doxycycline, and the nurse will know that. And it works in the workflow, and brings back the subtleties we need. We’re not going to get away from these templates anytime soon, but the artfulness can be retained. So that’s what you’re gaining with Nuance and real-time voice-driven notes.

What would your advice for other CMIOs be, regarding moving forward on physician documentation issues?

I think that using voice-to-text is really the answer to the pushback that electronic documentation is cookie-cutter and that the notes become redundant and that the story is lost. Voice-to-text is the answer in terms of bringing those nuances back to the notes.

Is there anything the industry can do to further optimize the physician documentation process?

I personally believe that the traditional structure of a SOAP [subjective, objective, assessment, plan] note needs to be dissolved or eliminated; and I know some others in medical informatics feel that way, too. The thing is that that methodology lends itself to paper-based documentation; but following the SOAP format in the EMR is leading to note-bloat. You don’t need to reproduce or repeat every lab or telemetry finding in the EMR; that’s already contained. And I think putting the assessment and plan at the top is very helpful. And one complete physical exam during the hospital stay is certainly necessary; but documentation by exception really highlights what’s changing in the notes. So what’s clinically relevant is having a very difficult time sticking out in the note now, because we have to do so much for Medicare and for the attorneys, so I think we really need to restructure how we’re doing progress notes. And hopefully, with some of the changes in the Affordable Care Act will change that, where some of those progress notes will be what’s clinically relevant, instead of a bloated dead whale on the beach.

Is there anything else you’d like to add?

I have a lot of pride in Oklahoma and in our health system, and how we responded to the tornado, and I’m appreciative and thankful of our whole team, and certainly, they deserve recognition.


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