One of the thornier, more complex challenges in the ongoing evolution of electronic health records (EHRs) and computerized physician order entry (CPOE) systems has been the ongoing tension between free-text documentation and drop-down menu-based documentation choices for physicians. In the paper-based world, physicians have traditionally followed the “SOAP”—Subjective, Objective, Assessment, Plan—format for creating progress notes, with subjective or historical information presented first, followed by objective findings (physical exams, lab results), and concluding with the assessment and plan. With the emergence of the EHR, however, and the ability to electronically append very large amounts of information to any document or set of documents, many physicians have found the traditional “SOAP” format to have become unmanageable, and have found a different sequence, known as “APSO” (Assessment, Plan, Subjective, Objective) to be preferable in an electronic setting, as the APSO approach brings forward the assessment and plan, often the elements the busy clinician is looking for first. The challenge becomes particularly acute in the context of what’s called the “copy-forward” problem, in which successive physicians continue to add to a core set of documentation, until the electronic information on a particular patient becomes wildly unwieldy and nearly impossible to parse without a very intensive investment of time on the part of subsequent physicians.
In an article entitled “Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital,” which was published in the journal Applied Clinical Informatics and appeared online at the beginning of May, Jin Hahn, M.D., Christopher Longhurst, M.D., and three other physician colleagues at Lucile Packard Children’s Hospital (LPCH), Palo Alto, Calif., described a unique approach to resolving the free-text-versus-dropdown tension. As the authors note in the summary paragraph to their article, “Electronic physician documentation is an essential element of a complete electronic medical record (EMR). At Lucile Packard Children’s Hospital, a teaching hospital affiliated with Stanford University, we implemented an inpatient electronic documentation system for physicians over a 12-month period. Using an EMR-based free-text editor coupled with automated import of system data elements, we were able to achieve voluntary, widespread adoption of the electronic documentation process,” they explain.
As the authors note later in their article, “The rollout [of the hospital’s physician documentation capability] involving 46 inpatient services (31 medical and 15 surgical) was completed in 12 months. A total of 254 specialized note templates were created for these services. In addition,” they note, “181 system-wide auto-text shortcut macros were created that brought in vitals, intake and output, medications, laboratories, and teaching physician attestations. As a result of this effort and the previous CPOE and nursing documentation implementation, the entire hospital is now considered to be level 6 on the HIMSS EMR Adoption Model.”
Dr. Hahn, the hospital’s medical director of clinical informatics, and Dr. Longhurst, its CMIO, spoke recently with HCI Editor-in-Chief Mark Hagland regarding the process of physician documentation implementation they pursued at LPCH, and the lessons learned so far. Below are excerpts from that interview.
What were the most important elements for you in pursuing your innovation around physician documentation?
Christopher Longhurst, M.D.: There were three takeaway points for me in terms of what we accomplished. First, there’s this eternal struggle between free-text narrative versus structured data. And for many years, the informatics community weighed in on the side of structured data. The concept was, create structured data for outcomes, reporting, analytics, and decision support. But while the informatics community thought this was a great idea in theory, the end-user clinicians didn’t. So the first decision we described in the paper was that we rolled out a very free-text-narrative approach to physician documentation, and we mitigated the issue of not creating structured data, by occasionally creating forms when appropriate. So that really contributed to the rapid adoption.
The second point that I would make that was well-described and really important in the article, is that copy-and-paste is a problem with every implementation of physician documentation. I think this is a really well-described approach to trying to mitigate that. It wasn’t perfect by any stretch, but the carry-forward boxes that Jin described helped bring forward aspects of the note that improve workflow, but because you’re already carrying forward a piece of the note, you’re de-cluttering things.
And the third thing I think that’s interesting is the search for data in the electronic health record. How do you find everything when you have all these notes online, not just the physician’s notes, but the nurse’s, and the chaplain’s, etc.? This is the first example of the APSO note, which describes a sort of bastardization of the SOAP note. So you actually put your assessment and plan at the top of the note, which is what doctors do anyway.
Was the SOAP note an artifact of the paper-based world?
Not really. It practice, it just hasn’t worked out as well as expected. So the APSO has been very successful here, related to finding things within the notes. And second, we’ve implemented the semantic search feature, and basically, the ability to basically “Google” the chart, has been well-received.
Jin Hahn, M.D.: As Chris mentioned, one of the issues is that electronic notes are not as easy to cruise over as paper notes. So one of the things that we did was to create the APSO note. And that makes it easy to see things at the top, without having to scroll all the way down to the bottom of the record; the other thing was the way we ordered the folders. You can go to the clinical documents and see them, and there’s a hierarchy of folders with different types of notes. And we use a special script so that the names of the specialties and note types are [visually distinguished], whether it’s a consult note, a progress note, or an admission note. So, for example, under each folder, you might have a specialty that’s mentioned, and you can quickly find if it’s a cardiology note or a neurology note, etc.
What have been the biggest lessons learned so far, and what would your advice be for other clinical informatics leaders, in this area?
Hahn: I would say that, given that physicians do prefer more of a free-text format, and they’re hindered by having to use multiple clicks, we’ve developed a system using a one-click method, which takes them to specialty note tabs; and they can continue to work on that note during rounds, and capture rounds, and then continue that note. So this is designed to fit within the[physicians’] workflow, and also allow them to use free text, as well as bringing in other data as they need.
Longhurst: Yes, I would reflect what Jin said. If you take a step back and realize what’s happened here, our vendor, Cerner, sank tons of money into developing this tool called PowerNotes, and we basically said, that tool is not satisfactory, and here’s a tool basically built on Microsoft Word, and this works better. So we’re basically saying that your developed tool doesn’t work so well. And literally, nobody has done this in Cerner, in the way we’ve rolled it out, though we were certainly inspired by colleagues from Los Angeles Children’s and Boston Children’s Hospitals.
I think this illustrates that CMIOs and other medical informaticists will have more say now in critical areas such as physician documentation, now that they have more skills and development.
Longhurst: I think that’s a great point. The existing tools are not necessarily always the best. My concern is that the vendors are reallocating resources to meaningful use and regulatory requirements, and have washed their hands of physician documentation, while the tools are just not there yet.
Hahn: AMDIS [the Association of Medical Directors of Information Systems] is trying to write a white paper on reworking clinical documentation. While that is a great paper and project, there are still a lot of unintended problems and consequences, such as the copy-forward problem, that still exist. Because you have errors of commission and omission in that context. And we’re trying to help vendors help us in that area. The same thing is true in terms of the note-forward format, and the problem with scrolling. So those are some of the issues we’d like vendors to tackle.
What would your advice be for CMIOs and other medical informaticists in all this?
Longhurst: We’re certainly not the first to document an ROI on this, but we did show a massive reduction in related transcription costs; so taking an approach that was both fiscal as well as focusing on clinician workflow benefits was very well-received. In addition, I would endorse what Jin said, that informaticists should consider that collecting data in a certain way might not necessarily be the best thing to do in terms of supporting clinicians’ and patients’ needs.
Hahn: Also, for the most part here, the increase in time required to document using this format, was mostly in the ICU, but not the on the general acute-care floors, where most notes are created.