As electronic health records (EHRs) increasingly become universalized, an unintended consequence of that very positive trend has been the growth of “note bloat”—the electronic agglutination of physician notes and other data, clogging the EHR with overly much content, often poorly organized, leading to physician frustration and even potentially, medical errors.
With physician documentation reform advancing now in U.S. healthcare, that phenomenon was identified by the editors of Healthcare Informatics as one the publication’s Top Ten Tech Trends this year. The article on that Trend appeared in the March/April issue of the magazine, as well as online here.
One of the industry leaders interviewed for that Trend article was Vivek Reddy, M.D., CMIO at the 20-plus-hospital UPMC (University of Pittsburgh Medical Center) health system. Below are excerpts from HCI Editor-in-Chief Mark Hagland’s interview with Dr. Reddy earlier this spring on this subject.
What seems apparent is that a combination of elements is pushing physician documentation reform forward: the OpenNotes movement, intensifying consumerism, and the emergence of more advanced and sophisticated information technologies. What are your thoughts on all this?
I agree with how you’ve framed this. Even simply incorporating the OpenNotes movement and consumerism, the reality is that everything is becoming focused on transparency, and patients understanding better their health and understanding the treatments they’re being offered. 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.
All of this is going to drive a different level of health literacy expectations. And that automatically changes a number of aspects of this for physicians—not only an intensified focus on accuracy, but also aspects of style and completeness in documentation. In that regard, I think it’s actually a pretty exciting time. You know, 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. It’s turning it all on its head.
In that sense, the patient is being brought in as a partner in their care, right?
Yes, that’s right.
In your view, what percentage of physicians understand the shifts that are taking place right now?
On a scale of 1 to 5, I think most are around a 2 or 3. I think physicians are starting to open up to the idea that this is an exciting new world, but there’s still some trepidation around opening notes, because it forces a physician to be completely transparent towards the patient. I don’t think everyone is completely on the bus and super-excited about it, but the majority of physicians are getting to the understanding that this is something that’s coming and shouldn’t be resisted any longer.
We’re coming out of what has historically been a paternalistic view of patients, then?
I think the word “paternalistic” has a sort of pejorative ring to it. What I will say is that we’re getting into a world where there is so much more information available to patients. In the old days, if someone wanted to learn about a disease, the only information would be to go to a library and look it up or to trust their physician. Now, with the rapid expansion of information online and everywhere else, you’ve got a new way to get information. And so that information in the physician’s head is a little more liquid. So the physician has to embrace a little bit different role of adviser, interpreter, and change agent, not just an informer. But to have a real discussion about their conditions.
What should CMIOs and CIOs be doing right now?
We’ve sort of fallen into the trap of documentation pathology. 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. Here at UPMC, we were actually able to break down some myths, and really got to the why of behaviors and patterns [with practicing physicians]. By having that dialogue, you can actually then crystallize on some key talking points as to why you want to change or reform the documentation paradigm in your facility or organization.
So a few years ago, at UPMC, we brought together all the stakeholders around documentation, including high-volume clinicians, and put everyone in a room and said, what do you think makes a good physician note? And by having a multidisciplinary discussion, 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.
And the billing engine tends to be the loudest [in terms of asserting the needs of billing and finance people within the organization], but even the needs around billing can be broken down further, and some of that is interpretation and mythology. What I would tell other organizations is, take advantage of the negative energy; nobody’s happy with the quality of physician documentation. However, that feeling of despair that it can’t get better—you can use that negative energy, that dissatisfaction among physicians. We used that, and got physicians around a table. So we should not be afraid of that.
You and your colleagues have been working on this for at least three years now, correct?
Yes, that’s correct, over three years.
What have been some of the key changes you’ve been able to make as a result of your work in this area?
We’ve been able to reduce the amount of information that would automatically populate in the notes, like long lists of medications and labs. The old defaults in our notes had been auto-populating all this information. So we were able to bring down the note bloat. The second thing was, we started to notice that physicians were using the notes to overcome barriers in the EMR user interface. So if it was just too difficult, too many screens, boxes, or clicks, in the EMR, the note became a crutch for pulling information. And that is a workflow and EMR design problem.
We needed to give physicians ways to cull the information they needed, and not pollute every progress note… So it led us to improve the EMR, to EMR optimization, out of the fact that people were complaining about the note, but really, the were complaining about the fact that they were using the note to find information that was in disparate places in the EMR.
And the forward evolution of health information exchange will also influence this work going forward, correct?
Yes, as payment reform kicks in and health information exchange kicks in, people will want HIE as a real communications tool, not just a data dump. I do see people falling into just a stream of communication with the cognitive part of medicine; I see us being able to use structured data elements, to exchange data, about labs, meds, etc. And I think that information, whether that sits above or outside the CCD [continuity of care document]—I think that providers will discover that rapid-fire communication of specific pieces of data will be powerful, and not just the note. And slowly, that will decouple itself from EMRs, and become a different concept. That will be the fun information. As organizations realize they need a different for the cognitive and communication aspects of documentation.
What do you call that phenomenon?
For lack of a better word, I call it the patient blog, if you will. A constant feed of information, where people are commenting or contributing from different points [in the continuum of care] Or a wall of sorts, for the patient… instead of it being bogged down by a lot of structured data or information.
And it always sounds daunting and duplicative to say that a physician can crystallize 30 data sets in a note down to a short paragraph around what they want to share with a specialist or look for. But in reality, that will require us to retrain our physicians to say, you know, brevity is actually a good thing. It becomes something that feeds off of each other. In the same way we learn that very long-winded prose around the medical history, we will see physicians learning to communicate in short snippets. And I look forward to that transformation occurring.