Summer 2022

Diagnosis: A Serious Case of Note Bloat
By Kory Anderson, MD, and Kearstin Jorgenson, MSM, CPC, COC
For The Record
Vol. 34 No. 3 P. 14

When it comes to charting, brevity rarely rules the day. This can make for cumbersome care and a slew of other headaches. How can organizations shrink this problem down to size?

Note bloat doesn’t get much attention on a wide scale. It’s recognized as a problem, and it gets discussed in industry articles and papers, but cross-functional committees aren’t created to tackle it. A champion isn’t identified to initiate training, monitor quality, and advocate for the importance of cohesive and concise notes.

With many competing priorities in the everyday lives of care providers, does note bloat really need to surface at the top of the priority list?

One of the challenges contributing to its neglect is that lengthy, unclear notes are not a one-and-done problem that education teams can solve. It’s quite the opposite—it needs tender loving care. It needs consistent and continuous time and attention. And unless a bad outcome can be directly tied to bloated notes, many facilities will continue to dedicate focused resources elsewhere.

It’s understandable. Many care settings are understaffed and overworked, so asking teams to take on one more initiative could feel like overload.

Staying late after a shift to complete notes or sifting through pages of them to identify correct codes aren’t likely anyone’s top choice to spend their time, however. And notes contribute to some of the most important decisions—care plans, codes, and billing, just to name a few.

While clear and concise notes might not win awards or receive patient recognition, taking steps to eliminate note bloat will keep those who interact with them focused on where they’re needed most and, in turn, create an environment where a higher quality of care is possible.

The following are five suggestions to help make tackling note bloat more digestible.

Identify Why and How Note Bloat Happens
The path to note bloat is paved with good intentions. Sometimes it’s to create a resource comprehensive of all information so the note communicates everything in one place. That way, the next care team doesn’t need to go looking for answers.

Sometimes it’s out of fear of litigation. Should a lawsuit be brought forth, all information is, once again, in one place to demonstrate all Ts were crossed and all Is were dotted.

It can also happen because today’s patients are highly complex. There’s an emphasis on capturing the full complexity of any given patient for risk adjustment and reimbursement purposes, among other reasons. To do that can require a long problem list with lots of explanation and context.

Bloat can also occur because of how the technology created to make notes more efficient is being used. Templates are one such area. Originally meant to make entry fast and easy, they can grow as care providers add sections important to them. Now there might be sections for inpatient and outpatient medications that weren’t there at the outset, maybe a few for different risk scores. All the while, the template grows, getting bigger and bigger. It’s not a question of whether this information is important and worth tracking—because it is—or that continuously improving templates shouldn’t happen—because it should—it’s a question of whether what’s being added to the template is needed.

While the intent behind all of these actions is good, it can result in a lengthy note in which it’s difficult to find the sought-after information. Identifying note bloat’s root causes can help facilities understand where to focus attention first.

For instance, if looking at templates to determine whether all the sections are needed is one such cause, be judicious and mindful of all the different sections. Is there so much information in there that no one can look at it and readily discern what’s going on with the patient? If the answer is “yes,” that could mean action is needed, and teams will need to be able to reconcile.

Start with troubleshooting one root cause and see how making changes in that one area affects the whole. Then start building from there, addressing more root causes until notes fulfill their decided purpose.

Define the Note’s Purpose and What It Is Not
Why do we document every single day what’s going on with a patient? On the surface, there’s one answer: To understand what’s happening with the patient and what steps need to be taken next.

Seemingly simple enough, this could show up in different ways from physician to physician. To some, it could mean the patient’s entire history from their first day to the present is included in each note. Lists of medications, drugs administered, tests performed, thought processes, and citations to source those thought processes might all be meticulously captured in detail.

On the opposite end of the spectrum, understanding what’s happening with the patient could mean short summaries that lack detail and action.

Notes need to communicate to the care team what the clinical situation is, recommendations and thoughts on a care plan, and why that care plan is the best course of action at that moment.

The key phrase here is “at that moment.” While the patient’s history and previous treatment plans should be taken into account, it’s what’s happening on that day and what needs to be done next that should take priority in the note.

Let’s say a patient had sepsis. They presented with a fever, a fast heart rate, and a high white blood count. They also had pneumonia. Those details, as well as what care was provided, are relevant to that day’s notes. But if they were resolved, they don’t need to take up as much space in subsequent notes. It could change to “sepsis is resolved; completed antibiotic course.” It clearly says what happened and what needs to be done (if anything).

Keeping in mind the next care team that will be taking over the patient’s care is something to consider. If they’re picking up 15 new patients, they likely don’t have time to spend 10 or more minutes reading a single patient’s note.

Without a singular, clear, and specific definition that outlines what a note is and what it is not, notes can turn into a choose-your-own-adventure exercise.

Think of Note Bloat as a Cross-Functional Issue
While physicians are responsible for note creation and also affected by them in their day-to-day work, they aren’t alone. Notes are the source of many important decisions across the spectrum of care and a patient’s experience. Because of that, notes should be thought of as a cross-functional issue in which a number of groups have a vested interest in their quality.

Clinical Documentation Integrity
As one of the teams most affected by notes outside of the care team, clinical documentation integrity (CDI) should play a key role. If notes are verbose and unclear, the longer it will take for coders to review, which decreases the coding team’s accuracy and productivity and increases the potential for missing specific codes.

If notes aren’t submitted in a timely manner because physicians are taking a long time to complete, the CDI review process is affected. While in pending status, notes can’t be coded or reviewed for any potential gaps from a financial or a quality perspective.

In turn, these slowdowns directly affect accounts receivable. It’s when notes are clear, concise, and specific that the CDI review process is best set up for success.

Billing
The codes identified in notes directly affect what gets billed and to whom. Physician billing as it pertains to medical necessity and justification of the care plan, and hitting certain level codes each day, is an important one to watch.

Notes being copied and pasted day after day with little change, despite the patient being stable, increases the risk of inappropriate billing, audits, denials, and more.

Compliance
Is the facility and its physicians putting themselves at risk? Notes can uncover compliance gaps and areas that need additional attention.

EHR
As the ones who put the templates together, EHR folks might not have as direct an effect on patient care as some of the other groups. Nevertheless, their work is critical in making the systems that help power efficient and effective patient care possible.

Looking through a cross-functional lens to understand who is affected by notes can lead to solutions on finding ways to address bloat, who should be involved, and where responsibility should lie.

Use Technology to Augment, Not Replace, Human Thought
With caseloads where they are today and the level of complexity of patients, it’s unrealistic for physicians to manually type every single note, and it’s unrealistic for CDI teams to thoroughly review every record.

Technology can and should help ease the burden, but its role isn’t one of replacement—it’s one of augmentation.

Computer-assisted physician documentation solutions that employ artificial intelligence, such as the one used at Intermountain Healthcare, is one way to help bring together the needs of the physicians and the CDI team when it comes to notes.

The solution helps prioritize cases and identify opportunities for CDI teams. As for physicians, it can help keep them focused, nudging them if they’ve missed or forgotten to do something or if something might need additional explanation.

Such technologies can be another set of eyes and ears teams otherwise wouldn’t have, contributing to better care delivery. One situation, as an example, is with end-of-life patients. Technology can assist in better communication across the care management team so critical conversations can happen earlier, hospice can get involved sooner, and other necessary steps to care for that individual patient are identified and acted upon in a team effort.

What technology shouldn’t be used for is to completely replace the critical thinking skills of humans. Templates, dictation, copy and paste, and prepopulated autofill phrases should be leveraged to create sustainable, efficient work habits.

Think of Note Bloat as a Patient Experience Issue
Thus far, much of this discussion has centered on deconstructing the structures and assumptions associated with note bloat. What they culminate into is that bloated notes aren’t a case of verbose physicians. Rather, it’s a patient experience issue.

Regardless of what a patient presents with—a sore throat, pain in their chest, a broken bone—they’re seeking the attention of professionals. They need help and want to be seen, heard, and taken seriously.

The time a clinician spends looking at a computer screen, completing or reading notes, is time taken away from being face to face with the patient and understanding what’s happening. If they’re trying to rush out of the room to quickly finish a note before the next patient, that’s less time with the patient. And if they’re consistently staying late after their shifts to complete notes, they’re unlikely to show up the next day at their best.

As for coders, the time they spend reviewing notes is time that affects the accuracy and timeliness of billing. And if they need a fine-tooth comb to parse through each note, they’re likely not going to do their best work either.

Patients need their care teams to be there for them. From the moment they come in the door all the way to receiving a bill, notes are behind it all. It’s going to take a team effort from across different functions, disciplines, and needs to make it work.

Note Bloat Prognosis
Note bloat doesn’t have to plague care settings. Digestible, actionable steps and making progress where it’s possible will help treat a dynamic challenge. What will your team do to handle note bloat at your facility?

— Kory Anderson, MD, is the medical director of physician advisor services, CDI, and quality, and a hospitalist at Intermountain Healthcare’s trauma facilities who’s responsible for physician utilization review, CDI, physician education, physician appeals and denials, and quality care and reporting.

— Kearstin Jorgenson MSM, CPC, COC, is the operations director for Intermountain Physician Advisor Services, supporting the operations for physician utilization review, CDI, physician education, and physician appeals and denials. Jorgenson has worked at Intermountain Healthcare for 20 years, holding several leadership roles and operationalizing a new department of 60 individuals, including nurses, coders, and analysts.