Documentation Burden: Receiving the Ideal Note

Dani Nordin (athenahealth), Chair, EHRA User Experience Workgroup, and Bryan Bagdasian, MD, MMM (MEDITECH)

This is the fourth in a blog series highlighting the discussions from the 2022 EHRA & HIMSS Physician Committee Summit: Meaningful and Streamlined Documentation.

While the ability to create an ideal clinical note is obviously important to the delivery of healthcare, equally essential to the process is the ability for other providers and systems — as well as the clinician’s future self — to use those historical notes to understand the patient’s history and inform future care decisions.

In our second breakout session, we focused on the problem of receiving and comprehending clinical notes received from others. Participants in the group included a mix of behavioral health specialists, hospital nurses, and informatics experts, including representatives from multiple EHR vendors. Using a combination of verbal prompts and a live-updated Mural board, we facilitated a discussion to answer the following questions:

  • Who is the intended audience for the notes we create?
  • From whom or what do we regularly receive notes?
  • What are the characteristics of an ideal note to receive from another provider?
  • What frustrates you about the notes you receive from others? What are the most frustrating types of documentation to receive?
  • What do we see as the barriers to receiving clinical notes that we can easily comprehend and use?

Themes and Opportunities

Several themes emerged from our discussion. We share these, along with opportunities for both EHR vendors and clinicians/health systems, in the following section.

Distinction between documentation and charting. The tension between structured data — required for billing, patient monitoring, etc. — and unstructured narrative was one of the primary themes that arose in discussion. To many participants, documentation referred to the narrative of the patient’s condition, their progress against it, and what the clinician planned to do as a result (i.e. History of Present Illness, Assessment/Plan, etc.). Other structured elements, such as vitals, orders, assessment scores, etc., were important for tracking the patient’s overall progress, and for other aspects such as regulatory or billing; these things were most commonly referred to as charting. While both are vital aspects of clinical communication and the health record, the ultimate audience for each, and the way each should be displayed to the user, differ.

The tension between structured data — required for billing, patient monitoring, etc. — and unstructured narrative was one of the primary themes that arose in discussion.

Overuse of “copy forward” accelerators creates note bloat. The ability to copy forward previous notes can greatly accelerate documentation for providers, particularly when a client is seen frequently for the same problem. But when the same notes are carried forward visit after visit, and either changed minimally or added to in each visit, it results in a cascade of bloated notes that other providers and systems have to contend with as they try to understand the story reflected in the narrative. Exacerbating this is the inability in most EHRs to easily track activity/interventions around the same problem over time — e.g. how a patient’s medication dose has changed over time, or which interventions (physical therapy, injections, etc.) have been tried for a patient’s chronic pain. This leads some specialists to copy their previous notes forward and continually build upon the patient narrative within individual visit notes, increasing the length of the note to unsustainable degrees.

Over-rotating on comprehensiveness instead of documentation by exception. Another common issue was a tendency for some clinicians to include everything possible in a note, rather than focusing on aspects of the patient’s condition that were abnormal or had changed. While regulatory and billing concerns can exacerbate this (e.g. “the level of information you need to bill a level 5 note,” mentioned by one participant), another issue was the use of point and click templates, available in most EHRs. Some participants complained that other providers felt compelled to include a finding in every single area on the template, even if the findings were normal, making it more difficult for others to find the systems that were abnormal when treating the patient.

Opportunities for EHR vendors

Provide multiple ways to view and export clinical notes by default. For events that include both documentation and charting (e.g. surgery, which includes an operative note, narrative nursing notes, and structured charting elements), have both an export of the narrative notes and a combined surgical chart that includes the full record, including the structured documentation captured during the surgery. Clinicians will need the narrative notes to inform post-op discussion and care, and the combined surgical chart is an important component of the patient’s overall chart, as well as being required for auditing and regulatory purposes.

Prioritize narrative elements when exporting or summarizing care records. A common complaint of notes received from other providers or carried over from interfaces is the need to sift through structured information such as the patient’s allergy/problem list, demographics, and other information to get to the information the provider needs to make the immediate care decision — most often the chief complaint, assessment/plan, and history of present illness. Prioritize these sections when formatting care summaries or interface messages. Additional structured chart data can be included at the bottom of the document for ease of reconciliation with other systems.

Make it easier to see the “history” of a specific problem. For many clinicians, particularly in the specialties, their focus is on a specific subset of the patient’s problem list — and they need to see what they, the patient, and other providers have tried to address that problem so they can decide on the next step in the patient’s care. When they are unable to do this, they resort to workarounds such as copying forward previous notes to create a “history” within the current encounter, or they complain bitterly about the EHR to their administrators. Consider ways of displaying the timeline of interventions and clinical notes, centered around a specific problem in the patient’s problem list, to mitigate this issue.

Opportunities for clinicians and health systems

Think about the audience(s) for a clinical note as you are writing it. Once created, your clinical note may be:

  • sent to the patient or their caregiver(s) as a care summary, either printed or through the patient portal
  • imported via interface message (HL7 or CCDA) to another EHR
  • exported as part of a medical records request
  • listed/summarized elsewhere in the patient’s chart in a timeline or document view
  • reviewed by another clinician responsible for providing care to this patient
  • reviewed by billers, coders, and authorization professionals to ensure payment is received for the care provided

While the EHR can handle many aspects of formatting the information within notes for these different audiences, clinicians have a responsibility to ensure their narrative clearly and concisely communicates the primary information which supports their clinical decision making. Additionally, with the increasing call for interoperability and patient access to their own clinical data, language used in the note should be accessible across a variety of readers — including those with limited clinical knowledge. Avoid using “copy forward” accelerators as a way to continue building upon the patient’s story, and focus on capturing just the information that is relevant to that patient’s visit. Focusing the note on this critical information will benefit not only clinicians who need to review the note later, but also billers and coders who often complain about clinicians notes not having the right information to support the expected E/M level.

Encourage documentation by exception over trying to capture everything. Structured templates and questionnaires can be significant accelerators to documenting care, and can provide a visual reminder of things to look out for when examining a patient for a given condition or visit type. However, when clinicians feel compelled to enter something on every single item in a structured template regardless of its clinical significance, the resulting output creates a sea of irrelevant information they and other clinicians will need to sift through to find the most important content. Practice administrators and clinical directors can ease the burden by encouraging clinicians to report only the most clinically significant findings for a patient when using these tools.

Conclusion

Ready or not, the evolving purpose of an “Ideal Note” has moved beyond one of its primary purposes: revenue generation. Today’s healthcare environment demands digital communication handoff throughout the continuum of care which aligns with the Institute of Medicine’s (IOM) framework for quality as defined by the following domains: safety, effectiveness, efficiency, equity, and patient-centeredness. 

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