‘Clutter is stuff on the page with no value added to it.’
Brian Jacobs, MD, is a pediatric critical care physician before all else. But there’s quite a lot to his “all else.”
As executive director at the Center for Pediatric Informatics and The Children’s IQ Network at the Washington, DC-based Children’s National Medical Center, Jacobs is also the CIO and CMIO.
He got there the old-fashioned way: Pointing out a problem and asking that it be fixed.
“The ICU is a very toxic and tech-laden environment,” Jacobs says. And because of that, it offers the opportunity to make a lot of mistakes. And that worried him. So, Jacobs began to complain about it, and lo and behold, he was put in charge of fixing it back in 2008.
Since then, he’s learned a lot about getting the biggest bang for the buck from electronic health records, and one of the key things is getting the notes to be clutter-free. They may be electronic, but that doesn’t mean they are automatically easy to read. Far from it.
Jacobs says in a way, the ROI for EHRs is misleading, with odds seemingly stacked in their favor. On the plus side, EHRs are: more complete, legible, accessible and can be auto-populated and searched. They can provide diagnosis codes and they’re good for billing. On the other hand, they can sometimes lack quality information and are by far, too cluttered.
[See also: Who Writes Clinical Notes?]
Jacobs was determined to make EHRs more valuable, and that’s where what he affectionately calls his `one note per day per patient’ policy comes in.
Where does all the clutter and confusion in EHRs come from? And more importantly, how can it be eliminated? Here is some insight from Jacobs:
What to do about too many notes
It’s not uncommon in teaching hospitals to have six to seven notes per day on one patient, by the time the attending physician, residents, consultants, other doctors and fellows check on the patient. Before Jacobs instituted the requirement that all physicians add their notes to the same document, there was just too much information for any one clinician to wade through and find the latest on the patient’s care. In most cases, the frustrated and rushed clinician would end up not reading all the notes. If nothing else, this was downright dangerous to the patient.
“We wanted to cut down on volume of notes but still retain high quality,” Jacobs says of the one note program. “It’s actually one note per team per patient per day; one giant multi-contributor note. They still may be all writing their components, but it’s one note.”
First, the resident generates an electronic note from a pre-programmed template before rounds begin at 7:30 a.m. “The start is a resident’s note that is augmented by anyone who has something to augment at the end of the day. The resident discusses what’s in the note with the entire team, and amends it as needed.”
There have been requests to add nurses to the ‘one note,’ but so far that hasn’t happened, Jacobs says, though he admits it’s a good idea.
[See also: ‘Note bloat’ putting patients at risk.]
Cutting down on the clutter
Paper notes were 90 percent clutter-free; “people didn’t put gibberish in hand-written notes.” EHRs, on the other hand, have 60 percent clutter in them. “Clutter is stuff on the page with no value added to it,” Jacobs explains. Some is added information from auto-population. For example time stamps that go all the way to the seconds. The auto-populated terms for treatment and medications in electronic records is long and formal, not the shorthand style of paper notes. When you add a lot of this, there is a whole lot of unneeded, unwieldy information in the notes.
Jacobs tackled clutter by creating a scoring system for the notes that evaluated notes for completeness, readability, quality and clutter. He found that 60 percent of the EHR notes at his facility were clutter. Being aware of it, “we got better over time,” Jacobs says.
Physicians would have, for example, four complete blood counts in one day, with 20 results. “All of a sudden, you have 80 lines of data in the note,” Jacob says. “Some of this is under the control of the physician, and some of it is auto-populated by the computer.”
Jacobs says he knows as a CIO he needs to allow some end-user flexibility around this. Some physicians prefer more expanded data than others, but he is already seeing some improvements in the look and feel of the note, with the added awareness the scoring has created.
In addition, vendors are helping. “EMR vendors are getting smarter about the tools and are designing the notes more meaningfully for people, giving individuals and organizations the ability to make a better note,” Jacobs says optimistically. He is excited that some vendors have added the ability to use highlight tools in the note. This is important, he says. Without highlighting, the text has all one look and feel, though some of the information could be drastically more important to know. “The difference between ‘coding’ and having a rash is a big difference,” he says.
“You would think a lot of this would have been obvious from the beginning,” Jacobs says. He attributes some of the lack of these capabilities to the failure of EHR vendors to get end-user input in the design process.
End-of-day note
EHRs pose a big problem with “copy forward.” Clinicians were copying and pasting the same end-of-note from the day prior, for days on end, yet “no two days are the same for a patient,” Jacobs says. These notes should never be the same. It negates the whole idea of an end-of-day summary. The cut and paste capability is the culprit for this in EHRs. Paper notes always had a fresh end-of-day note “scribbled” by the physician.
Jacobs was able to work with his EHR vendor to block the cut and paste capability enterprise-wide in some cases, particularly with the end-of-day note. Problem solved. Jacobs made it clear end-of-day notes should be a fresh summary.
Problem lists
Even before EHRs, physicians have always been challenged to keep an up-to-date problem list, which is now a core requirement under Stage 1 of the EHR incentive program.
“Until meaningful use, there wasn’t a lot of incentive in most organizations to keep one,” Jacobs says. “The Joint Commission would come by and say, ‘where is your problem list?’ And people would scramble.”
In addition, problem lists often have a smattering of descriptions for the same problem. They aren’t consistent. Jacobs wanted to fix that.
In the end, the best solution was to have the EHR programed to prompt the clinician who writes a problem in the note to add it to the problem list. This can be automated, prompting the clinician to select the problem from a drop-down menu to include in the list as s/he describes it in the note. “It encourages them to keep a problem list,” he says.
Billing
Last, but not least, Jacobs wanted to find a way to make billing quicker, more efficient and less painful. Back in the days of paper, the doctors would drop off their notes every three days or so in a box in the billing department and just pray things would all work out. “We left a lot of money on the table.”
Interface the note with the bill. Put a little section in the note that allows the physician to select the CPT codes for the day’s work. “The way we sold this to the doctors was to tell them, ‘you have to write a note every day anyway.’” If they could also select the CPT code, that will only facilitate quicker reimbursement. We begin billing that night.
In conclusion: the five-part obligation for the physicians in Jacob’s ‘one note per day per patient’ plan is:
- Write the note
- Select a diagnosis
- Select the CPT code
- Make sure the note has the right date
- Sign it
Of course there was some brief mandatory training, but the go-live to EHRs went well, including the ‘one note” plan. “It was sort of an easy sell,” Jacobs said. “For the most part, people pretty widely embraced it. It was much more successful than I thought it would be.”
