Something really interesting is happening these days around physician documentation. For years now, as patient care organizations have implemented electronic health records (EHRs), the shift from paper to electronic documentation has led to some unfortunate unintended consequences. Chief of these has been the phenomenon of “note bloat”—the electronic agglutination of physician notes and other data, clogging the EHR with so much content, often poorly organized, leading to physician frustration and even potentially, medical errors.
Though some preliminary physician documentation reform had been emerging in the past few years, the OpenNotes Movement and broader consumerism are flipping the script these days on physician documentation. With patients now being handed an ever-larger share of their bills via high-deductible health plans from their employers, and with expectations rising, as consumers in every other area of services can easily access and even control their data and information, a shift is taking place that is pushing the leaders of patient care organizations to conclude that it makes sense to bring patient further into engagement with their doctors by letting them see their doctors’ progress notes and other data and information—which, after all, is their information anyway, it is often pointed out.
But allowing patients to see physician notes means that those notes must be presentable, readable, and understandable. Thus, the burning platform needed to reform physician documentation.
CMIOs of organizations moving forward in this area agree—this is a trend whose time has come. Indeed, “All of this represents a focus on transparency, and patients understanding better their health, and the treatments they’re being offered,” says Vivek Reddy, M.D., CMIO at the 20-plus-hospital UPMC (University of Pittsburgh Medical Center) health system. “So there’s this huge shift towards greater awareness, and also using documentation as a way to help patients co-manage their diseases—so that you understand your treatments and the rationale between them.” Indeed, Reddy says, “This is going to drive a different level of health literacy expectations. And that automatically changes not only accuracy, but style, and completeness aspects of this, for physicians. I think it’s actually a pretty exciting time. You know,” he adds, “in the old days, the doctor would take a note on paper and keep it in a lock box until the next time they saw the patient; but all this is changing that dynamic.”
Brian Patty, M.D., vice president and CMIO at Rush University Medical Center, in Chicago, agrees. His view: the key involves streamlining and simplification. “When I look at this, what I see is that not everything needs to be documented by the physician,” Patty says. “And the care team note should build throughout the visit. Let’s take a primary care visit: the patient shares information at the beginning, the patient sees a nurse and then a physician, and possibly others. And the primary element is the assessment and plan, for physicians to document. So that takes the burden off the physician for documenting for certain kinds of documentation capture on behalf of outside souces.”
The bottom line? “We need as much as possible to capture that reportable data in a way that’s not burdening the physician,” Patty says. “And we need to capture that data so that the physician note is captured over the course of the visit, so that not everything is the burden of the physician. And we need to use NLP [natural language processing] to capture discrete elements out of a prose note. That will allow the physician to get back to dictating a note, whether using voice recognition or transcription, but being able to dictate a note that is clinically meaningful and concise, and these data elements are pulled out of that note and fed into various reporting requirements.”
Bill Reed, a partner in the Moosic, Pa.-based Huntzinger Group, says he sees both patient/consumer and physician desires involved. “This is moving ahead not only because of patient desire, but also because of provider desire,” he says. “We send tons of codified data back and forth. But there’s a lot of rich information in notes that historically has not been well passed along. So providers and payers will both want this. But the conceptual problem with OpenNotes and similar phenomena is that some providers will be reluctant to share that information because of the lack of the patient to be able to understand it. For example, my experience is that the abysmal level of patient portal utilization to date is because of the lack of literacy on the part of patients: they can’t comprehend the terms. And that will be a barrier.” Still, he agrees with Rush University’s Patty that mid-level practitioners and other clinic staff will be able to lessen the burden on physicians in practice when it comes to explication for patients.
Jody Cervenak, a Pittsburgh-based consultant with the Chicago-based Chartis Group, and a former senior IT executive at UPMC health system, says she recently led a discussion at Carnegie Mellon University with about 30 physicians getting their master’s degrees in medical management, around the topic of, as she puts it, “When will we stop thinking about notes in an isolated way and begin thinking about [documentation] as a collaborative process? I’m the instructor for the IT track” in that program, she says. “In fact, note bloat is very frustrating for physicians receiving notes. And one of the questions was, will the consumer movement finally change this and reframe this towards consumer documentation, patient documentation? And absolutely, the answer is that when you start sharing notes with patients, that creates a forcing function where patients are correcting the record. And the Open Notes movement will absolutely have a forcing function in terms of improving documentation.”
All those interviewed also agree that inevitably, another aspect of all this is the inevitable shift towards breaking up the EHR into messageable pieces of discrete information, rather than continuing to have to share entire CCDs (continuity of care documents), as most often happens nowadays. But to get to that next phase of evolution, CMIOs and other physician informaticist leaders are going to have to retrain their colleagues in documentation, as has been happening for three years now at UPMC.
“We’ve sort of fallen into the trap of documentation pathology,” UPMC’s Reddy says. “We’ve either been documenting based on the do one teach one model—you see it and do whatever someone told you—so the perceptions on how and why we should document, need to be examined closely.” Fortunately, by going through a collaborative educational process with physicians in specialty-specific groups, Reddy notes, “We were actually able to break down some myths, and really got to the why of behaviors and patterns, and by having that dialogue, you can actually then crystallize on some key talking points on why you want to change or reform the documentation paradigm in your facility or organization.”
Will the path ahead be challenging? No doubt about it. At the same time, say industry experts, it is both doable and inevitable.
