'Note bloat' blurs true patient status

Long-winded documentation, cut-and-paste practices challenge quality of care
By Neil Versel
12:00 AM

Healthcare organizations with long-established electronic health records run the risk of "note bloat" and compromised patient safety unless they standardize physician documentation procedures and limit the amount of cutting-and-pasting doctors have to do.

Note bloat and copy-and-paste practices captured a lot of attention at the most recent CHIME forum last fall, and the topics continue to spark debate in most hospitals across the country. So far, there appears to be no remedy.

“It's been challenging for docs and healthcare systems in general … to produce a document that reflects the patient story in the most concise, complete and informational way,” said Jody Cervenak, principal of Pittsburgh-based health IT consulting firm Aspen Advisors.

Cervenak quoted 17th Century French mathematician and philosopher Blaise Pascal, who wrote, "I have made this letter longer than usual, only because I have not had the time to make it shorter."

Or, in the concise words of G. Daniel Martich, MD, chief medical information officer and vice president of physician services at the University of Pittsburgh Medical Center, "More isn't always better."

Between 2009 and 2012, UPMC made a concerted effort to move physician documentation from paper to the EHR. Now, doctors produce 3.4 million encounter notes a month in the Cerner inpatient EHR and 4 million notes into ambulatory systems, according to Jim Venturella, CIO of the organization's hospital and physician services division.

But in a survey of close to 2,000 UPMC clinicians, less than half of respondents thought the notes were valuable for patient care, Venturella said.

Similarly, electronic physician documentation had become unwieldy at Geisinger Health System, a dominant player in another part of Pennsylvania. Geisinger, an Epic Systems EHR customer, gives clinicians and coders several options for documenting cases, including dictation, templated pick lists, direct keyboard entry, interfaces from ancillary systems and even auto-generated text. Each has its shortfalls.

"Providers can't type. That's true even in this day and age," said CIO Frank Richards.

Auto-generation can lead to unnecessary data. Cut and paste saves time, but can cause a lot of problems by creating redundancy. Templates can create a lot of variation because Geisinger historically has allowed physicians to create their own menu items, Richards said.

Both Geisinger and UPMC have kicked off efforts to streamline physician documentation. Geisinger came up with guidelines for physicians to create "a quality note," Cervenak said. Coders spend less time coding the note and the patient experience is better, she explained.

Geisinger has applied analytics to analyze all the items in every patient problem list, Richards said, and created a single, standardized problem list across the organization. The most common medical complaints in each department appear at the top of the list to make it easier for physicians.

"We're in the process of exploring natural language processing as a way of extracting more value from dictation," Richards added.

Geisinger also is starting to use more sophisticated computer-assisted coding on the back end of documentation, before sending bills to insurance companies. The health system is trying to move some of the coding to the front of the cycle so physicians can have a more complete medical history, based on previous claims, at the start of a patient encounter, he said.

Management instituted a strict policy on copying and pasting, requiring any free text in the patient record to be attributed to the original author and date and time of entry. It is "rarely appropriate" to copy and paste an entire document, Richards said, and clinicians are not allowed to copy images from the picture archiving and communications system into the EHR.

At UPMC, officials decided to bring clarity to the subjective, objective, assessment, plan, or SOAP, note. "We broke that down," Martich said. “It should not be a summative note. Every progress note shouldn't be a running blog."

Earlier this year, the UPMC institutional governance board voted by a narrow margin to prohibit copy-and-paste in the assessment and plan parts of the SOAP note, according to Martich.

UPMC now is talking about what the organization has dubbed "SOAP 2.0," which Martich said stands for succinct/specific original (without plagiarism), accurate (not what Martich called "sloppy and paste") and problem-oriented.

"Ours is really about improving quality and improving the signal-to-noise ratio," he said.