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.
If this is in fact the case, then it seems logical that vendors and providers consider delivering tools in which the primary focus is on organization and review, rather than the assembly of free text and structured, codified details. It's the age old dilemma, what is primary and what is secondary?
This is not to say the secondary is unimportant, it’s just secondary. And the data from Columbia University strongly suggest we should re-evaluate the tools and their design relative to the primary job – organization and review. Today, primary and secondary are reversed, because reimbursement is placed ahead of clinical needs.
With the advent of Accountable Care Organizations I see a very distinct opportunity. By definition, ACOs will operate within a system that rewards service and value that, in effect, replaces the E&M documentation-based payment system. This will result in Physician Documentation that is clinically oriented, shorter and more useful for improving quality and helping hospitals to meet Meaningful Use criteria. Physicians will be able spend more time focused on providing quality care, because the burden of documentation will be reduced as it is simplified.
These are changes to our documentation standards that will need to happen at a regulatory level according to a Part 1 comment made by Dr. John Chelico. In this instance, I think a regulation may be advisable to provide vendors and their partners with the guidance to develop changes to their systems that are consistent with the broader goals. In addition, Dr. John Kenary, also in a Part I comment, discussed the need to use Adaptive Design as the key to achieving positive results. This appears to be an idea whose time has come.
In conclusion, I think that the need for public discussion, experimentation, and probably some regulatory guidance are necessary to evolve the core design challenge to Physician Documentation at a faster pace with lower risk for vendors and their partners. We cannot, at the end of the day, settle for an approach that is simply replication with some innovation. What we have is a clear call to action for transformation, something the team of smart people I work with and numerous others I come in contact with are pursuing.
What do you think?
Graphic Credit: Opening graphic, depicticting some of the relationships around online documentation was taken from the AMIA poster by John D. Chelico, MD, Michael N. Cantor, MD, and Aaron Elliot, MD, Belleuve Hospital and NYU School of Medicine, New York, NY. Thanks to the team and management at NYC Health and Hospital Corporation for a series of many accomplishments and publications, including this poster clipping.