Physician note-writing is an opportunity to teach, share ideas, and solidify clinical decision-making. Yet as billing requirements and copy-paste functionality have increased in recent years, the utility of writing and reading these notes has declined steeply. In addition to the dehumanizing "tyranny of clicks and auto-populated fields," (Rosenbaum, "Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine"; N Engl J Med 2015; Oct 2015; 373:1585-1588), we have all experienced the embarrassment of reading notes riddled with glaring, late night errors that become a permanent part of the medical record. The bulkiness of auto-populated information in notes also reduces the reliance on written notes for inpatient communication. While in-person verbal communication is critically important, the EHR is not meeting its potential as a reliable account of patient care, and the burden of the "tyranny of clicks" is detracting from our ability to produce notes that are as meaningful as possible. Furthermore, the extent to which errors in notes contribute to poor patient outcomes at our center is not known. In order to improve medical education, increase efficiency in medical care, and reduce avoidable errors, there is an urgent need to re-evaluate how we compose our inpatient progress and consult notes.
This proposal has three main goals. First, we will track “typographical” errors in notes, comparing anonymized data by author type, service, time of day signed, and total number of notes written by that author per day. We hypothesize that errors will be prevalent, and that the number of errors will be higher among individuals who write many notes per day and sign their notes later in the day.
Second, we will characterize the teaching value of notes (graded by specific criteria) across services. We hypothesize that the teaching value of notes will be inversely proportional to the bulkiness of excess information contained in auto-populated fields.
Finally, we will perform rigorous anonymous provider surveys to determine their trust in the EHR documentation. We hypothesize that trust in the accuracy of EHR documentation is low, and that the majority of providers will view EHR documentation as a hindrance to rather than an aide for patient care.
These initial goals will lay the foundation for an intervention in which we will test two methods of note writing - free text versus autopopulated - and compare outcomes of documentation accuracy, trainee learning, provider satisfaction, and patient care.
Goal 1. To track errors in notes. A smart programmer (name TBD) will develop code to identify inconsistencies and errors in notes. For example, when physical exams describe inconsistent findings that can never co-exist (for example, "obtunded" in the same exam as "neurologic exam nonfocal"); failure of a treatment or hospital day to be updated (same day "X out of X" of antibiotics listed for several days in a row); or list medications that have been discontinued (this will be complicated but should be able to be cross-referenced between A/P section and active med list on that day's note). The scope of errors in medical documentation will thus be defined as a starting point.
Goal 2. To characterize the teaching value of notes. The burden of charting has taken away the joy of an important purpose of writing notes - reflecting on the patient and describing one's thinking process in words. We will take a sample of notes from different author types (including consultants) and de-identify the author and patient information, then subject the notes to a grading system by which the teaching value of the notes is measured. The criteria will include differential diagnoses, literature review, and descriptions of clinical reasoning.
Goal 3. To assess provider trust in the EMR. Using surveys targeted for different types of providers, we will assess the ways in which EMR notes are used – for verifying recommendations, understanding patients, and confirming plans. We will solicit providers’ main sources of dissatisfaction with EMR documentation and their ideas for improvement – addressing “the third problem: many clinicians know what they want — but haven't been asked” (Rosenbaum 2015).
Achieving these goals has the immediate potential to improve clinical service and education. Once the systems for tracking these errors and measuring teaching value have been developed, the project will be scalable beyond UCSF to other academic teaching hospitals that rely on EPIC. The time frame for implementation will be feasible prior to December 31, 2016 as our goals are well-circumscribed and will be focused on inpatient documentation only. Eventually, the intervention stage of the project will allow UCSF to be a pioneer in testing new methods of ensuring quality patient care through note-writing and transcending the drive for physician notes to be the sole source of billing documentation.
What about outpatient notes? This is a critical area with its own pitfalls and opportunities and thus will require its own plan for assessment and implementation, which can be addressed at a later time. The scope of the current proposal is strictly for inpatient notes.
What if people start paying more attention to their notes because they know this is going on? That would be great! It would be a terrific outcome of the project and would not affect the overall purpose, which is to enhance the meaning and teaching value of the documentation included in the EMR.
What about billing??? This intervention will be the first step toward our combating the problem that a focus on billing has taken over our focus on patient care. We have the opportunity to be at the forefront of necessary reform of the medical system causing "enduring harm," job dissatisfaction, and poor patient care. This proposal will establish our leadership in implementing measures to ensure that physicians and our patients survive the “transitional chaos” successfully.
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