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Special AHIMA Edition September 2013

A ‘Note’-worthy Collaborative Takes Shape
By Lisa A. Eramo
For The Record
Vol. 25 No. 13 P. 14

Boston’s Beth Israel Deaconess Medical Center is piloting a novel approach to documentation.

Medical record documentation in a teaching facility often follows a long and winding trail that goes a little something like this: A medical student writes a note. An intern writes a note. A resident or fellow writes a note. An attending physician writes a note. A consulting physician writes a note, sometimes contradicting all of the previously documented information. “What you’ve ended up with is 17 pages of contradictory, incomplete, and sometimes copied information that’s unusable,” says John D. Halamka, MD, MS, chief information officer at Beth Israel Deaconess Medical Center (BIDMC) in Boston.

In an age of patient-centric care, this disparate approach to documentation simply isn’t sufficient any longer, says David K. Vawdrey, PhD, an assistant professor of biomedical informatics at Columbia University Medical Center in New York. “Much of what is currently documented in the EHR is in response to increasingly complex and prescriptive medico-legal, reimbursement, and regulatory requirements,” he says. “The American Medical Informatics Association has suggested that the primary purpose of documentation should be to support patient care, and that documentation for other purposes should be generated as a by-product of care delivery.”

As health care moves from a private and closed environment to one that embraces patient engagement, EHR vendors and applications must do the same, says Nick van Terheyden, MD, chief medical information officer at Nuance Communications.

The question is how? Believe it or not, the answer could lie in social media—not literally but in terms of the transparent and interactive approach that it inspires.

BIDMC will be piloting a prototype this fall of what Halamka refers to as a “social approach” to documentation, requiring providers to document collectively in one note using disease-specific templates to ensure that appropriate quality indicators are recorded. An attending physician then would sign off on the note to authenticate its accuracy. “Instead of five different people coming together and writing their own narrative, a care team is on the same page,” Halamka says. “At the end of the day, the attending physician says, ‘I’m the attending physician of record for this patient. I take responsibility for signing this note as representing the collective team wisdom.’”

This social approach is similar to the one that Facebook and Wikipedia use—that is, multiple authors contribute to one entry or discussion, and an audit trail identifies the individuals who write, delete, or edit any of the information. Halamka says the audit trail is key because it will illustrate the “behind-the-scenes” action that results in a final note. He hopes all providers at BIDMC will use this method no later than October 1, 2014—just in time for ICD-10-CM/PCS implementation.

Not only does the pilot include socially constructed progress notes, it also incorporates natural language processing and ICD-10-CM/PCS–specific documentation prompts to quickly create detailed, structured, and actionable clinical data. For example, when a physician documents a fracture, he or she will be prompted to specify laterality, distal vs. proximal, open vs. closed, and simple vs. comminuted. The system is cloud based, meaning physicians don’t need to directly install any programs or applications onto their computers.

“This new documentation paradigm upends the existing model, wherein each team member documents in a separate location, resulting in silos of information,” says Vawdrey, a supporter of the approach. “We recently discovered that 38% of nurses’ notes and 16% of overall notes written at a respected academic medical center were never read by anyone.”

Collaboration and communication is the ultimate goal of social documentation, says Deborah Kohn, MPH, RHIA, FACHE, CPHIMS, CIP, principal of Dak Systems Consulting. Instead of documenting within separate notes, providers will presumably read the collective note as they contribute to it. “The dietitian might go in and make his or her note at 10 AM, but the doctor was making rounds at 6:30 AM. They can’t talk to each other, but they literally collaborate and communicate by the socially designed collaborative progress note,” she says.

Vawdrey agrees, noting that the strategy makes for more meaningful notes. “Collaborative documentation, I believe, will result in less redundancy and less superfluous information,” he says. “The most relevant information will naturally bubble to the top, and hopefully the phenomenon of note bloat will decrease. If there are fewer notes with higher salience, I believe they will be more likely to be read by other team members. I think sometimes notes are not read because it requires too much time, too many clicks to open them.”

Teaching facilities particularly can benefit from social documentation, Kohn says. “It gets confusing when you have a lot of medical students, residents, and interns all looking at the same patient and providing their two cents,” she says. A socially constructed progress note has the potential to be a robust learning tool that can allow medical students, interns, and others to learn from one another and their colleagues, she adds.

Challenges and Barriers
A social approach to documentation poses several challenges and barriers, some of which may be more difficult to overcome than others.

First, there are regulations to consider. Many wonder whether Medicare and The Joint Commission will accept a socially constructed note. “We have to work through the legal aspects of whether our regulatory bodies will see this as an improvement,” Halamka says.

“Everyone would have to get on board and change,” says Sylvia Hoffman, RN, CCDS, CCDI, CICDI, president and CEO of Sylvia Hoffman Consulting. “Change is slow. Look at how many times ICD-10 has been postponed.”

Second, there are technological barriers. Vendors must rewrite a significant amount of programming to incorporate social documentation architecture for progress notes. They also must be able to provide a far more detailed audit trail than what’s currently available. “Medical record systems don’t do this today,” Halamka says, adding that once a physician signs a note, it cannot be edited, meaning the concept of group authorship doesn’t exist.

However, technological complexities aren’t a barrier at BIDMC because the medical center has a homegrown EHR. “We’re not constrained by the conventions of the standard electronic health record,” Halamka says. “We are often the pilot for many state and federal activities.”

Third, there may be physician resistance. This may be particularly true for attending physicians who must sign off on what Hoffman terms a “sanitized” note or the final discharge summary. Individual accountability for pay-for-performance and quality metrics may turn some providers off to the idea entirely. “A physician will get either the credit or the ding,” Hoffman says. “In this day and age, where we’re collecting data for pay-for-performance and quality metrics, I don’t know if I’d want to be a hospitalist to whom all of this socially approved information is ultimately attributed.”

Halamka agrees that physicians may be slow to embrace the change. “This is not the way that doctors have worked for the last 80 years,” he says. At BIDMC, an ICD-10-CM/PCS steering committee is helping to manage the culture change. Physicians have been receptive to the idea of social documentation thus far, although the pilot likely will solicit more feedback, according to Halamka.

“I believe that social documentation would be embraced by some providers and resisted by others,” Vawdrey says. “For many physicians, note writing is closely integrated with the cognitive processes involved in understanding a patient case and formulating a plan of care. Disrupting that process may have negative consequences. On the other hand, care delivery is becoming more collaborative. It makes sense—to some people at least—that documentation should be collaborative as well.”

Fourth, social documentation may not support current reimbursement models. “Although clinical care is increasingly performed by multispecialty teams, traditional payment models have operated under an individual fee-for-service paradigm,” Vawdrey says.

Fifth, recovery auditors (RAs) may push back. “Some RAs are saying that they want to see information flow throughout the record,” Hoffman says, adding that, in essence, the RAs want to see information repeated while they don’t want to see isolated diagnoses documented and coded.

Where Coders and CDI Specialists Fit
Then, of course, there are the coders and clinical documentation improvement (CDI) specialists. What role would they play in a social documentation approach? “Social documentation reduces multiple, contradictory documentation to a single note,” Halamka says. “[Coders and CDI specialists] are going to love it because it’s going to make coding a whole lot easier.”

Hoffman’s not so sure social documentation will eliminate contradictory information. Only in an ideal world would the attending physician actually go and speak with the consulting physician before changing any documentation. “It’s the deleting other people’s words that I have a problem with,” she says. “What if the attending physician failed to meet core measures and is denying that the patient had an MI [myocardial infarction]? If I were the consulting physician, I would want to make sure that my words were in the chart saying, ‘I thought the patient had an MI.’ I wouldn’t want my words deleted from the chart.”

Another concern is that physicians don’t understand coding and coding guidelines. Hoffman says the individual deleting, fixing, or changing information may omit important coding information, which could affect the principal diagnosis, the present-on-admission indicator, and other key factors.

Social documentation essentially will force coders to examine a note’s audit trail to make sure they’re not missing any important details, Hoffman says. “You’re not really saving coders or CDI specialists any time because you’re looking back to see what was deleted or tweaked,” she adds.

Looking Ahead
“You certainly hope that as accountable care grows throughout the country that documentation itself changes,” Halamka says.

ICD-10-CM/PCS also may inspire the emergence of novel documentation approaches, according to Halamka. “There’s the compliance aspect of getting the correct code, but then there’s the other issue of getting the documentation rich enough to justify the code you select,” he says. “The problem is that today, what many people document doesn’t have enough detail. [This approach] would spread the documentation burden across many team members.”

BIDMC is linking its social documentation pilot with its ICD-10-CM/PCS implementation strategy. Halamka says physicians have been on board largely because they view this approach as a way to alleviate the burden placed on them to document more specifically.

There likely will be a period of trial and error as vendors continue to try to find the perfect solution that puts the patient front and center, experts say. “I often hear physicians say, ‘I didn’t even know the patient had a decubitus ulcer because that’s on the nursing notes, and I don’t see those,’” Hoffman says. Functionality that allows providers who are documenting in the record to easily access other providers’ notes via a drop-down menu while documenting their own individual notes will be key, she adds.

Patient engagement will be another important—and necessary—element of social documentation that will likely begin to emerge as the approach is vetted and altered. “Patients will become the agents of change in our new world of health care delivery,” van Terheyden says, adding that this not only reduces errors but also improves quality of care.

Two years ago, BIDMC, where patients have had access to the EMR since 1999, granted patients a passageway to progress notes. “Not only do we share with the patients what it is that physicians write every day, but we also allow the patient to add his or her own thoughts,” Halamka says, adding that patients will continue to have access to their records when the medical center rolls out its social documentation pilot program as well.

— Lisa A. Eramo is a freelance writer and editor in Cranston, Rhode Island, who specializes in HIM, medical coding, and health care regulatory topics.


BIDMC Expands Online Access to Clinician Notes
Online access to the notes physicians, nurses, and other clinicians write now is available for all primary care, orthopedics, and rehabilitation services patients at Beth Israel Deaconess Medical Center (BIDMC).

The medical center plans to have outpatient notes from all specialties available by the end of 2013 (with a majority of departments and divisions on board by November), reaching almost 250,000 patients. Inpatient notes are expected to become available in 2014.

“BIDMC is among the first medical centers in the country, and the first in Massachusetts, to invite patients to participate in this transparent approach to care,” says Mark Zeidel, MD, chair of BIDMC’s department of medicine. “We are confident that it is the right thing to do. Why? Many of our primary care physicians and patients were among more than 100 volunteering primary care physicians and 20,000 patients who completed a one-year, multicenter trial of OpenNotes. Doctors involved saw benefits for their patients and little, if any, burden for themselves.”

“What we see increasingly is that engaged patients have better outcomes,” says Kevin Tabb, MD, BIDMC’s president and CEO. “The study results showed that OpenNotes is a way to engage patients, so I’m really proud that our institution is adopting it in a big way.”

After each appointment or discussion, patients will receive an e-mail inviting them to read their visit notes on PatientSite, BIDMC’s secure patient website. Approximately 116,000 patients will have the opportunity to read their notes with this initial expansion.

Patients who took part in the 2010 OpenNotes study reported that reading these notes helped them better understand their health and medical conditions, take their medications as prescribed, and feel more in control of their care.

“I think it definitely helps patients take more ownership of their care and be more engaged in what’s happening,” says Kim Ariyabuddhiphongs, MD, a primary care physician who participated in the study. “This is a clear step towards, ‘this is about you, this is what we’re doing, and this is why it’s important’ and it just brings the patient into that whole discussion just a little bit more.”

— Source: Beth Israel Deaconess Medical Center