Colin Banas, M.D., CMIO at VCU Health System in Richmond, Va., has been working with his colleagues to lead an initiative to reform physician documentation at the academic medical center-based integrated health system. Dr. Banas is one of many CMIOs around the U.S. working to improve physician documentation in patient care organizations, for the sake of everyone—physicians, nurses, other clinicians, administrators, and above all, patients. In that regard, was one of the CMIOs interviewed by HCI Editor-in-Chief Mark Hagland for the magazine’s April-May cover story on physician documentation reform.
Banas, who has been at VCU since 2002 and in informatics since 2007; and who has been CMIO since 2010, works with a team of six physicians, six nurse informaticists, and a training team of about 12 people. He has been in the trenches working with his colleagues to establish and expand documentation governance and leadership, note reform, and physician education around reform. He spoke earlier this spring with Hagland for the April-May cover story; below are excerpts from that interview.
What are you doing around physician documentation these days at VCU?
We’re moving forward along a number of dimensions. To begin with, we are fully electronic on our inpatient and outpatient sides on physician documentation; and there are a variety of tools we’re using. There are folks using structured documentation within Cerner called PowerNotes. Some folks still do structured dictation, and some do HotSpot voice recognition documentation. And we have a Documentation Council, as part of our Office of Clinical Transformation, and I’m the lead of that office. That’s where new requests get vetted or denied, and implemented.
How big is the documentation council?
The core group that meets weekly is 10-12 people—clinicians, analysts who do the code writing; members of the training team and mobile training team present; and then once a month, they have a bigger month, they have a steering committee meeting with all those other groups. There were close to 30 people in those monthly meetings. So it’s big. So my advice for the CMIO in terms of how to structure your governance… And champions, too. And for CIOs, it’s the notion of resourcing it. I’m lucky enough to have a CIO who recognizes the importance of these clinical informaticists. And we pay them for their time; they have protected time to participate in this. It’s a model that’s now being adopted across the country, but I don’t think it’s standard yet.
What kinds of issues are cropping up?
A variety. For example, CMS [the federal Centers for Medicare and Medicaid Services] or the Joint Commission will have all sorts of requirements around perioperative documentation. They’ll craft requirements so that you can’t even sign the note unless you’ve done certain key things. That’s proven very effective. The tool available to us in Cerner enabled us to require that certain things be required before a note can be signed. And our documentation council is chaired by a pediatrician.
Can you provide examples of such requirements?
One example is around immediate post-op documentation—there are certain elements that must be available in the note the second the patient leaves the operating room, in order to satisfy the Joint Commission. We’ve been able to standardize that process of post-op documentation; and we’ve had similar success in standardizing our discharge summary process. That’s required collaboration between our inpatient and outpatient physicians. What is it that the outpatient doctors need to see? We’ve been pursuing dialogues around such questions. And we’ve built our discharge summaries in that iterative manner.
What has the timeframe been around this activity?
The perioperative documentation was put in place three or four years ago, and the discharge the discharge summaries about a year and a half ago.
What have been your organization’s major learnings in this area?
It’s really changing the way we think about documentation. In terms of the discharge summary, we needed to think about it not as a required document that helps the patient’s stay and gets us a bill, but rather, as a transition of care document. So putting the inpatient and outpatient doctors together to discuss this, we were able to get a much cleaner document and enhance patient safety.
There’s a sort of urban legend to the effect that there’s no way around the phenomenon of note bloat.
That urban legend definitely exists, and there are a couple of things that all collide to contribute to the problem. The first thing is a misunderstanding on the part of the clinician as to what is actually required. At VCU, we’re an academic medical center, and we’ve got a lot of residents, and they really have no idea how to optimally document. And so they tend to include more and more things. You have to remind them that we’re in a new era now with the EHR [electronic health record], and I have access to all that information, it’s just one click away. Sometimes, note bloat around lab values, vital signs, etc., is taking place because of deficiencies in the EHR system.
So, as a physician, I’ll start a note, and I’ll pull in information from the meds list, lab values, and vital signs on a patient, and it’s not because I need them to support my billing, for example, but because I don’t want to exit the note before I forget what those things are, and selecting, highlighting, and deleting them back out is a pain. So the problem there is EHR workflow, which doesn’t work in terms of the cognitive process of writing the note. There are actually people who are in fact abusing the tool; but you can say that about any tool. I hate the notion that we’re going to have to turn off copy-paste or copy-forward functions [because of untrained physicians working poorly with the tools available to them. Instead,]the trick is to engage in intensive monitoring, after training doctors, and indeed, in peer pressure, post-training, to eliminate poor note-writing practices.
What would your advice be for CMIOs and for non-clinician CIOs who will be involved in these documentation reform activities?
It sounds generic, but it really is that notion of collaboration across specialties with your peers. Our documentation council is chaired by a pediatrician, and interacts with our health information management director and also our regulatory and compliance workgroup. So if we’re going to construct a template or workflow, we’d better make sure it’s compliant, and legal, too; we’ve got a lawyer in that group as well.
