Design Principles for Physician Documentation in Electronic Health Records

1. Design Principles for Physician Documentationin Electronic Health Records Eric Rose, MD Clinical Assistant Professor, Department of Family Medicine and Division of Biomedical and Health Informatics, University of Washington Physician Consultant, IDX Systems Corporation http://faculty.washington.edu/momus/infodoc.htm

2. OUTLINE • Overview of physician documentation • Definition • Purpose(s) • Common structural conventions • Review of modalities for electronic physician documentation • The three dimensions of documentation tool effectiveness • Questions for discussion Eric Rose, M.D.

3. Overview of Physician Documentation • Definition—? Patient-specific information Generated by a physician Capable of being viewed as text • “Physician’s Note” = the viewable end-product Eric Rose, M.D.

4. Overview of Physician Documentation • Purpose(s)—? Inform subsequent care Inform current care (“writing-as-thinking”) Research Legal purposes Billing purposes Drive automated processes, e.g. “decision-support” (electronic-structured only) Eric Rose, M.D.

5. Why Should Documentation be User-Centric? The Physician’s Note is… First and foremost… A STORY Eric Rose, M.D.

6. Overview of Physician Documentation Common Structural Conventions for the Physician’s Note • The “SOAP” note (cf. Weed 1968) • The “H & P” note • The ICU note • The Therapeutic Procedure note • The Diagnostic Procedure note Eric Rose, M.D.

7. The “SOAP” note SUBJECTIVE: Mr. Gringoire is a 50-year-old gentleman who returns to clinic for followup of COPD. He continues to smoke approximately one pack a day. His shortness of breath is somewhat improved on Advair. There has been no other significant change to his symptoms since his last visit. His present medication regimen consists of Advair 500/50 one puff BID and Combivent MDI PRN. OBJECTIVE: GENERAL: Well-appearing male. VITAL SIGNS: BP 110/71, Wt 63.2 kg, HR 82, Temp 96.8, O2 sat 95% on RA HEAD AND NECK: Clear. There is no lymphadenopathy. CHEST: Clear to auscultation bilaterally. His expiratory phase is prolonged but there are no wheezes. ASSESSMENT: In summary, this is a 50-year-old gentleman with severe COPD who continues to smoke. I once again strongly stressed to him the absolute essential need for him to stop smoking as this is the only meaningful thing that will improve his pulmonary health. I have prescribed him Wellbutrin and he will plan on enrolling in a smoking cessation class per his health plan. Otherwise, he will continue to treat his COPD with Advair metered dose inhaler. PLAN: 1. Smoking cessation. 2. Continue Advair. 3. Pulmonary rehabilitation. 4. Consider leukotriene antagonist next meeting. 5. No current need for supplemental oxygen. 6. The patient will return to clinic in three months. Additionally, I again recommended considering a cardiac evaluation including a stress test to evaluate his mild chest discomfort as he has numerous risk factors for CAD. Eric Rose, M.D.

8. The “H & P” note IDENTIFYING DATA: The patient is a 40 year old male admitted for left lower leg cellulitis. HISTORY OF THE PRESENT ILLNESS: The patient presented to the Family Medicine clinic today stating that he was in his usual state of good health until about 5 days ago when he noticed pain and redness on the lateral aspect of his left lower leg. He had had an abrasion there from about 1 week previously … PAST MEDICAL HISTORY: The patient has moderate persistent asthma well-controlled on his current regimen (see below); no other significant PMHx. He has no known history of malignancy or thrombophilia. PAST SURGICAL HISTORY: None FAMILY MEDICAL HISTORY: His parents are both living and in good health… CURRENT MEDICATIONS: Advair 100/50 1 puff BID; Proventil MDI PRN ALLERGIES: No known drug allergies SOCIAL HISTORY: The patient owns a used bookstore, is married, and has one teenage son. He drinks approximately one alcoholic beverage per week, and denies use of tobacco or illicit drugs. REVIEW OF SYSTEMS... PHYSICIAL EXAM… ASSESSMENT… PLAN… Eric Rose, M.D.

9. Other Note Types (See handouts) Eric Rose, M.D.

10. Entry Modalities for Electronic Physician Documentation • Free Text (typed or dictated) • Fixed pre-composed text (“macros”) • Multiple-choice Entry (various UI widgets) • Direct importation from database Note—All modalities except free-text enable capture of structured data as by-product of the documentation process. Eric Rose, M.D.

11. The three dimensions of documentation tool effectiveness • Ease of note creation • Data quality of the note • How much of the relevant information which was obtained in the physician-patient encounter ends up in the note • How accurate the information in the note is • How richly imbued with meta-data it is (i.e. how much discrete data collection occurs) • Presentation quality of the note Eric Rose, M.D.

12. Discussion Questions • How would YOU design a physician documentation module for an EHR? • What are some of the design pitfalls for such a function? • How would you design tools for building pre-composed documents (“templates”)? • Should an EHR have one toolset for physician documentation and another for other users, or should the toolset be the same across user types? Eric Rose, M.D.

13. Discussion Questions • Can EHR-based physician documentation improve patient safety? How would you achieve that in your design? • How should physician documentation tools be integrated with other EHR functions? • What difficulties might exist in sharing documentation templates across separate organizations using the same EHR application? Eric Rose, M.D.

14. Discussion Questions • If you were implementing an EHR, how would you approach deployment of physician documentation functionality (and template design tools)? • What challenges or pitfalls might you anticipate in such deployment? Eric Rose, M.D.

15. Because physician notes tell a story, they are usually entirely or in part time-centric… “Mr. Jones was feeling well until about ten days ago when he experienced the onset of a dull, bifrontal headache. Over the following days, the headache steadily worsened and also seemed to become focused over the left parietal area; at the same time, he noticed the onset of a dry cough. About 2 days ago the headache started to diminish, but the cough worsened and became productive of yellowish sputum. Yesterday he noticed the onset of fever and flecks of blood in his sputum, and decided to call for an appointment.” What are the implications of this when it comes to designing physician documentation tools? Eric Rose, M.D.