As hospitals throughout the country sprint towards Meaningful Use, computerized physician order entry (CPOE), electronic medication reconciliation, ICD-9-generated diagnosis tables, nursing documentation, and bed side barcoding seem to be riding a tsunami incentivized by the American Recovery and Reinvestment Act of 2009 (ARRA). There is no shortage of excitement or consultants needed to attain these carefully crafted quantitative goals. In the wake of these rapid and aggressive hospital rollouts, there remains a relatively neglected application: electronic physician/mid-level provider (MLP) documentation. Electronic physician documentation (EPD) doesn’t enjoy any artificial excitement because it stands distinct from any current required stages in the Meaningful Use stage 1 program. The HIMSS analytics database (2012) suggests a disappointing 2.8% penetration of physician electronic documentation within their U.S. electronic medical record (EMR) adoption model. The most experience in physician electronic documentation is seen in emergency departments and early adopters of ambulatory EMRs. Electronic physician-mid level provider documentation, therefore, is looming on the near horizon for hospitals and ambulatory care providers implementing EMRs. EPD may be the electronic medical records’ best opportunity to improve communications, improve patient safety, and promote physician adoption of EMRs.
In traditional medical culture, there seems to be an unexplained acceptance of physician/MLP illegibility. There are countless jokes and cartoons about patients, nurses, and pharmacists trying to decipher physician handwriting. There are well-documented examples of poor handwriting leading to significant ADEs (adverse drug events). My personal experience is that approximately 33% of handwritten progress notes remain illegible, fragmented, and poorly organized. Electronic physician documentation, while not a perfect solution, can eliminate illegibility, and that simple functionality can have a positive impact on patient safety. Paradoxically, electronic documentation can meet physician resistance because it represents another electronic application that needs to be learned, and it can feel unnatural to seasoned physicians. Electronic documentation within the hospital environment allows a clinician’s impression to be immediately available to the chart, avoiding the turnaround time inherent in traditional dictation. Disadvantages to electronic documentation include a heavy influence of billing requirements that seem to degrade the note with superfluous bullets that distract time-pressured clinicians, dependence on developing new computer skills, steep learning curves that impact productivity, incorrect documentation that is auto-propagated, and a perceived inability to provide effective communications to caregivers.
Documentation issues are multifactorial. They involve the provider’s personal communication style; complex, changing, and poorly understood billing requirements; quality initiatives; legal ramifications; research issues; case management requirements; and revenue cycle management. Because electronic documentation will be evaluated by different end-users, there is no consistent standard on what constitutes a high quality note. A clinician will value the clinical content that is required for patient care while a coder will be searching for elements to substantiate their billing codes. Physicians and MLP seem to be overwhelmed with documentation requirements that many feel detract from patient care and negatively impact their productivity. ICD 10 conversion looms in the near future (October 2014), and with it come increased documentation requirements. The threats of matching billing codes and documentation persist in the background. The attitudes of physicians who do global billing are different than those who submit daily charges.
Modern electronic documentation generally involves dovetailing voice recognition with templates that require physicians to click through a laundry list of drop-down menus that ultimately create a document. There are also opportunities for the clinician to type additional “free text” comments. The templates are filled with structured vocabularies that serve as searchable options that are championed for data mining. Voice recognition differs from traditional dictation because it requires concurrent proofreading and a short list of verbal commands that need to be memorized. Voice recognition software does not misspell words; it mis-identifies words that will need to be corrected, and then the software needs to be “trained” to avoid future errors. The clinicians are thus tasked with learning new skills concerning structured vocabulary appearing in templates and incorporating voice recognition within their EMRs. In reality, there may be clinicians who will be unable to navigate an EMR because of poor computer and typing skills. Templates are probably superior for review of systems, incorporating past history, and documenting the physical exam. Voice recognition seems to have the advantage for documenting chief complaints, history of present illness, and discussing the differential diagnosis. Dictation is superior to templates when there is a need to tell a story or discuss a complex differential diagnosis. There is speculation that at the end of the day, structured data can be mined and thus analyzed to yield knowledge to improve healthcare delivery. The end-user can instruct the documentation program to import lab, vital signs, and results eliminating the need to hand copy these results into a paper progress note.
Prepare for Improvement, not IT
How should hospitals prepare for electronic physician documentation? Many are probably exhausted from stage I of Meaningful Use; healthcare systems are accumulating a long wish list of add-on programs and interfaces designed to reduce documentation redundancies and improve efficiencies. Electronic documentation may not be on that list. Hospital executives may be weary because they probably saw their quality metrics take a momentary dip from their CPOE implementations, and quality metrics may be incorporated into their performance incentives. Practicing physicians are worried about their time and productivity. How does one re-energize and engage another application in an already complicated electronic health record arena?
First and foremost, electronic physician documentation is not an informational technology (IT) project. EPD is a clinical documentation improvement (CDI) program that needs input from clinicians, health information management (HIM) professionals, billing experts, compliance officers, quality officers, and your ICD 10 team. These professionals should be involved in your early discussions before your go live. Healthcare systems have traditionally been criticized for poor communications and incomplete handoffs, and EPD represents a new system for communications that hopefully can improve communications. The learning curve for electronic documentation is steep, incremental, with maximal adoption occurring over several years. The structured nature of the electronic world can help instill discipline and raise awareness for physicians navigating the system. As more physicians are integrated into hospital systems, there arises a common need to improve documentation to maintain their revenue stream and justify their billing codes.
Education needs to be tailored to the needs of the individual physician and the individual service lines. Education needs to be customized to energize the early adaptors and convince the laggards. In non-teaching hospitals, everyone will need to know how to document, and the attendings cannot be shielded by residents the way they may have been for CPOE. Electronic documentation applications are robust and may require multiple sequential education sessions. Utilize your nurse practitioners (NPs) and physician assistants (PAs) to function as super-users to help educate the physicians with whom they work. Emphasize the need for formal education sessions, which can involve large classrooms, computer labs, and at-the-shoulder support. If your hospital has the skillset, you can create internal web-based training videos that can asynchronously educate your end users. Low-volume end users will either need to make a special effort to learn these applications, seek the help of local super-users, or restrict their documentation to voice recognition.
Electronic documentation may increase competition for your computer workstations. Individual sessions at workstations may be prolonged as clinicians create documents. Clinicians will soon learn that they will be able to create effective electronic documentation at work stations geographically distinct from patient areas. An IT “lounge” for physicians located near their regular lounge can become an area where physicians complete their rounds, mingle, ask questions, and exchange ideas. Metrics to follow during implementation include case mix index (CMI), HIM physician queries, and LOS (length of stay).
Negative unintended consequences will be seen and should be anticipated. Service lines that are accustomed to global billing (typically surgical specialties) may create notes that are too brief and filled with acronyms other clinicians may not recognize. Medical specialties may create notes that are too long, which other clinicians will not read. Just remember that because you can type in comments, clinicians should continue to avoid unacceptable abbreviations. If voice recognition is used, physicians will need to proofread and correct the dictations. Correcting a document created with voice recognition software requires the end user to know the correct voice commands or to use a mouse and keyboard. Physicians who are attracted to voice recognition originally because they have poor computer or keyboard skills will thus be required to revisit the issues they were trying to avoid. Automating or prefilling notes with irrelevant, incorrect, inaccurate, or verbose content will slow adoption.
Physicians should be instructed to document what they actually did. Copying forward documents with no useful purpose will need to be adjudicated by HIM and compliance professionals. Whether you elect a “big bang” global introduction or a geographical service line rollout, anticipate a lag until you see improved documentation. Initially, notes tend to be simple and then over time seem to mature as the end-users feels more comfortable. This maturation may take several years and emphasizes that physician electronic documentation is a continuous quality improvement program.
In summary, electronic physician documentation is poised to impact the clinician workflow and hopefully can improve communications among caregivers without negatively impacting physician productivity. If done correctly, structured vocabulary (templates) and voice recognition should be tools that physicians can utilize to build a robust electronic document that should fundamentally improve patient care. Unfortunately, electronic physician documentation has simultaneously become an enabler to satisfy bullet counters from billing specialists. Outside regulatory forces seem relentless in their insistence on complex formulas to link billing codes with documentation. While most physicians desire short, accurate, and concise documentation that tells a logical clinical story, they may see cluttered, verbose, redundant, and long-winded dissertations that may actually camouflage important clinical information. Meaningful Use stage 2 has just put electronic documentation on the radar; it’s time to road test it on a larger scale. Hopefully, payment reform will remove these distractions and we will realize the potential of electronic physician documentation as we improve the quality of clinician communication.
Joseph Catapano is a board certified internist and cardiologist currently working as the medical director of enterprise clinical information systems at Barnabas Health Care System in New Jersey. He also is a faculty member of the American College of Physician Executives. Catapano trained at Rutgers Medical School, Wayne State School of Medicine, and Hershey Medical Center and has a master’s degree in medical management from Carnegie Mellon University. Catapano’s expertise is physician adoption of electronic healthcare systems, and he worked for one year with a major vendor implementing CPOE (computerized physician order entry) at multiple hospital systems. Catapano may be contacted at