Electronic Physician Documentation is quickly becoming recognized as a nightmarishly messy and incoherent linchpin to Meaningful Use. Electronically capturing documentation previously done on paper or through dictation sounds pretty straight forward. It’s not.
Many of us use Microsoft Outlook or something substantially similar for our email. How often do we stop to realize that an email one moment might become all or part of a calendar entry the next? It may contain a “To Do” that we need to prioritize and track. Or it could have contact information we need to preserve so it’s usable in an address book, dialer, or end up in Excel. Are you using folders in email beyond the Inbox and Sent folders to better organize your work?
The point is that email is about more than messaging. It’s about organization in general and organization of work involving varied participants. If all we could do in Outlook is send and receive emails it would be a lot harder to use, because the automation with the subsystems such as calendars would become manual processes. That’s exactly the problem with Physician Documentation today. Too often, it’s conceived as a tool to construct a note. That’s just wrong.
Ideal documentation not only summarizes the patient’s current story, it captures the reasoning behind orders and serves as communication about the patient to other providers, as well as capturing the diagnostic and therapeutic plan. It also serves as a “note to self” that facilitates personal mental continuity. This is the ideal. In the real world, time pressure, energy and skill levels often result in less complete or effective documentation.
This is elaborated in wonderful detail by Mark Hagland in his recent article, “ Balancing Act: Can CMIOs and CIOs Make Physician Documentation Work for Everyone?” Mark has assembled the best current thinking on how leaders are addressing the problem. In this two-part blog, I’ll be giving you my take and invite you to share yours as well.
Replicate, Innovate, Transform
Years ago, Marion Ball impressed upon me that technology migrations require three sequential phases: Replicate, Innovate, and then Transform. It’s very tempting, and would seem to be more economical and faster, to attempt to skip phases under certain circumstances. That doesn’t work.
Today's Physician Documentation tools focus on replicating the existing note types physicians produce. For the inpatient world, the most complicated and critical of these is probably the discharge summary, often dictated days after discharge. In today’s world, there is no “magic” that automatically summarizes the relevant hospital course or problem lists, and as a byproduct, attesting to comprehensive medication reconciliation. Currently, when completed, these are additional organizational work steps, distinct from and prior to documentation. Clearly, this is more than delivering a working word processor with spell checking.
Before 2006, there was no mandate for concurrent discharge medication reconciliation at the time of discharge. There were no universally sanctioned and nationally defined quality measures to be addressed prior to final discharge. There was no mandate (spelled MU Stage 1) to produce a patient summary in a codified and semantically interoperable form.
With little or no contemplation for this fairly large gap, vendors and providers have thrust forward. They are producing disparate tools designed to reproduce the current process in an innovative electronic environment. Like other aspects of HITECH goals, the requirements, wants and needs, when looked at individually are reasonable. Collectively, the implementation burden can seem insurmountable. And then there is usability for that end user physician. Processes that should become one step, when separated out functionally become five total steps. This creates new potential gaps in care, since the probability of reliably following through on any single step by a rested, conscientious person is never 100 percent. Humans are not robots, the work is not widgetry, and economics leave all of us time and/or sleep deprived at times. Do you want to be our patient at those times? I don’t.
The current state, as I wrote earlier, is not ideal. Known care gaps are often implicit beyond the few common conditions that have received some badly needed attention. Conditions requiring things that should always be considered, for example, managing a patient with heart disease, stroke or diabetes, are often detailed somewhere. So while such knowledge is being transformed to become machine consumable, there is a higher expectation that it needs to transform physician documentation tools such that they guide and mentor.