Research: Enhancing the Quality of Documentation

A pilot study looks at obstacles to enhancing quality in the era of the electronic health records. EHRs have had many unintended consequences, including the declining quality of physician notes. 

ABSTRACT: A pilot study looks at overcoming obstacles and enhancing quality in the era of the electronic health record. Implementing EHR has had many unintended consequences, including deterioration in the quality of physician documentation. The authors evaluated resident-written progress notes at their medical center to demonstrate a quantitative and qualitative improvement through strategic template redesign and efficient collaboration with relevant stakeholders.

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Physician documentation mostly was a paper-related endeavor until as recently as end of the 20th century, when the rapid evolution and advancement in information technology fueled initiatives that pushed for the transition of health care documentation to electronic health records. The pretext was, EHRs could improve the delivery of health care by enhancing patient safety, as well as increasing quality and efficiency. Despite its promising potential, physicians and hospitals in the United States remained reluctant to trade their pens and paper for the EHR. By 2009, only about 12 percent of U.S. hospitals were equipped with either a basic or a comprehensive EHR.1

Congress responded with the 2009 Health Information Technology for Economic and Clinical Health Act, also known as HITECH, with the explicit intention to bolster EHR adoption and promote its meaningful use by U.S. physicians, with little regard to data from literature citing physician resistance as the biggest barrier to EHR adoption. Although this initially was voluntary, all public and private health care providers were required to demonstrate EHR use by Jan. 1, 2014, or be penalized for noncompliance in the form of reduced Medicare and Medicaid reimbursements. What followed was an unprecedented rise in EHR adoption at a rate that was higher than the computerization of other sectors within the U.S. economy of similar size and complexity.2-4  

Instead of making the process of physician documentation easier, the EHR has been associated with significant regulatory requirements; these issues have challenged practicing physicians, who now are expected to dispense high-quality, empathetic care in a shorter amount of time while simultaneously weaning themselves from paper-based workflow and entering the numerous structured data elements required for meaningful use. The EHR has forced physicians to take on a new, onerous burden of data entry in addition to the complex, high-level skills of a clinician.

In terms of changes in workflow, the issue of implementation of electronic physician documentation has been the most intrusive. Though the access and legibility limitations of paper records have been ameliorated, a significant number of unanticipated issues have arisen, leading to multiple complex problems.5-7 Electronic notes can take longer to write.7-9 Availability of timesavers such as “cut and paste” and “copy forward” have resulted in “note bloat”— cluttered notes with redundant, extraneous information that obfuscates, rather than clarifies, the pertinent clinical issues.10-12

“Cut and paste” carries significant risks of error propagation and loss of data integrity with a potential for compromise to patient care.13-15 A study cited this phenomenon as “e-iatrogenesis” — a term used to describe patient harm resulting from health information technology.16

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We decided to implement a quality-improvement project to evaluate the state of physician documentation at our medical center using quality metrics, identify the barriers to good note writing, and facilitate educational strategies to improve overall note quality.

Our hypothesis was that by adopting a multimodal strategy, we would demonstrate an improvement to progress notes within the surgical department. We also wanted to share the lessons we learned so others potentially could replicate our process improvement project within their own institution.

Methods

This study was conducted at Maimonides Medical Center, a 711-bed, nonprofit, tertiary-care, teaching hospital in the New York borough of Brooklyn. Physician notes were written using Allscripts Sunrise Clinical Manager. During this initial pilot phase, we limited our study to the surgical department. Only resident-authored, adult inpatient progress notes were included. This study was approved by the hospital’s institutional review board as a health care operation and was exempt from review under human subject research. This project was supported by a patient safety innovation grant from FOJP Service Corp. (the risk management advisers for our medical center) and Hospital Insurance Co. (our professional liability insurer).

We focused on the surgical department because of the relatively smaller number of house staff (compared with our department of medicine) and the fact that multiple authors of this article were located primarily in that department. To effectively capture the scope of the issues, we began by facilitating resident focus groups with the surgical house staff, using open-ended questions regarding the EHR and resident progress notes to elucidate such issues as what worked and what did not, as well as ideas for potential improvement. We also facilitated focus groups with senior attending surgeons to capture their positive and negative experiences with surgical progress notes. The information gleaned from these initial interactions helped chart our next steps, which were to focus on improving the overall quality of the progress note template, and to find realistic solutions tailored to the specific workflow requirements within the surgical department.

Through an iterative process over several months with senior attending surgeons and residents, our working group identified and differentiated important and superfluous information within the surgical progress note. The goal was to use group consensus throughout the process of creating a more-streamlined template and move away from notes that were data-rich but information-poor. From these sessions, we identified three general areas for improvement: the pre-existing note template, resident workflow and correlation of the progress note with the actual clinical situation.

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With respect to the pre-existing progress note template, we identified a large disconnect between our attending surgeons and residents regarding the way in which a progress note was generated. While they were accustomed to the final product that appeared in the EHR, they did not fully appreciate the complexity of actual progress note creation on the “back end.” Attendings were unaware of the large number of (only moderately relevant) multiple radio buttons (click buttons that allow the user to select a single option, as opposed to check boxes that allow the user to select multiple options from a given list) and how easy it was for a house officer to import verbatim (but not interpret) large volumes of laboratory, microbiology and radiographic data, leading to “note bloat.” As a result, we removed these radio buttons and disabled the importing of data. This was replaced with a free-text box, allowing physicians to comment on relevant clinical trends.

Because resident physicians were the primary creators of progress notes, we attempted to eliminate barriers that impeded effective progress note production. By simplifying the template into its most necessary elements, we sought to decrease the time to produce a progress note. For example, we simplified our section on the physical exam from a series of somewhat irrelevant and cumbersome individualized text boxes to a single, free-form space. In addition, we created a daily progress note template specifically for general surgery. Finally, we increased accessibility to relevant data, such as labs or radiographic studies, within the editable interface of the progress note, so residents could comment on changes in findings at the time of progress note generation. Through this process, we defined the minimum requirements for an acceptable surgical progress note, including physical examination, a summary of the hospitalization, addressing multiple active diagnoses and accurately capturing the daily events of patient care.    

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We elected to use a slightly modified version of the nine-item Physician Documentation Quality Instrument to assess the quality of progress notes used in our study.7 PDQI-9 is a validated instrument, which has the following subdomains: up-to-date, accurate, thorough, useful, organized, comprehensible, succinct, synthesized and internally consistent. Given some concerns we had for the PDQI-9 and our focus group, we retained the following five subdomains from the original instrument in our PDQI-9m metric: accurate, thorough, organized, synthesized and internally consistent. For each subdomain, the note is scored on a five-point Likert scale, from 1 (not at all) to 5 (extremely), for a maximum score of 25.

The PDQI-9m tool was used to score 30 progress notes from February 2017 (pre-intervention set) and 30 notes from January 2018 (post-intervention set). The notes were chosen from a random list of adult surgical inpatients. Note eligibility was based on the following inclusion criteria: written by a general surgery intern/resident, and availability of note written the previous day for comparison. Additionally, only one note per patient was scored. Based on the total score, notes were categorized as unacceptable (score less than 15), somewhat acceptable (score 15-19), or acceptable (score greater than or equal to 20).

All notes were scored by the lead author of this article after receiving appropriate training from a senior author. The training included practice sessions during which both scored the same notes and compared responses to ensure a common understanding of questions and definitions. The training concluded once scores from both authors were identical in six of seven sample notes.

General surgery residents were surveyed two months after implementation of the revised progress note template to assess for their perception of notes authored by residents, how conducive their work environment was for writing progress notes, clarity of their own notes, extent of feedback on progress notes and experience with the new progress note template.

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Appropriate tests were used to determine if data were normally distributed. As the data were abnormally distributed, the Mann-Whitney U test was used to compare the overall progress note quality between the pre-intervention and post-intervention data sets. For nonparametric data, the median scores with interquartile ranges are presented for each group. A subset analysis of nominal variables (unacceptable and acceptable notes) using Fisher’s exact test was used to compare the proportion of notes within each category for each of the two groups. All p-values were two-sided and statistically significant at less than 0.05. Statistical analyses were conducted using GraphPad Prism software version 7. The online resident opinion survey was created using SurveyMonkey. All tables and figures were created using Microsoft Excel 2016.

FIGURE 1: CHANGE IN NUMBER OF ACCEPTABLE AND UNACCEPTABLE NOTES, POST-INTERVENTION

saval figure

Results

Some 150 patients were admitted to the general surgery service in February 2017, and 184 patients in January 2018. Overall, a total of 60 resident-authored progress notes were graded using the PDQI-9m instrument. The median score was 14 (IQR=12-18.75) in 2017, and 22 (IQR=19-23) in 2018, (p-value less than 0.0001). Additionally, there was a significant increase in the proportion of “acceptable” quality notes, which went up by 43 percent post-intervention (p=0.002). Figure 1 shows changes within each note category in 2017 and 2018.

We received completed surveys from all 29 general surgery house officers. Of the 29 house officers, eight were interns (28 percent), eight were second-year residents (28 percent), five were third-year residents (17 percent), four were fourth-year residents (14 percent) and four were fifth-year/chief residents (14 percent).

TABLE 1: RESIDENT OPINION SURVEY

Conducted two months post-intervention, surveys were received completed from all 29 general surgery house officers (eight interns, eight second-year residents, five third-year residents, four fourth-year residents and four fifth-year/chief residents).

How do you prioritize writing a complete progress note relative to your other job requirements?

  • Top priority - 0 (0%)
  • Important - 21 (72%)
  • Not very important - 7 (24%)
  • Not important at all - 1 (3%)

When caring for a new patient, how effective is the last progress note in conveying the patient's current clinical status?

  • Very effective - 4 (14%)
  • Somewhat effective - 18 (62%)
  • Not effective at all - 7 (24%)

How conducive is your work environment (computer availability, free of distraction, etc.) to better note writing?

  • Exceeds expectations – 1 (3%)
  • Meets expectations - 12 (41%)
  • Below expectations - 16 (55%)

To what extent do you believe your progress notes provide an actual snapshot of the patient's clinical condition?

  • Extremely clearly -3 (10%)
  • Very clearly 14 - (48%)
  • Somewhat clearly - 12 (41%)
  • Not clear at all - 0 (0%)

How much feedback have you received on the quality of your progress note by senior residents and/or attending surgeons?

  • Lots - 4 (14%)
  • Some - 11 (38%)
  • Little - 12 (41%)
  • None - 2 (7%)

How would you describe your experience using the updated progress note template (after December 2017)?

  • Very positive - 7 (24%)
  • Positive - 10 (34%)
  • Neutral - 11 (38%)
  • Negative - 1 (3%)

As shown in Table 1, from a total of 29 residents, 25 (86 percent) said the most recent progress note was ineffective or somewhat effective in conveying the current clinical status of a patient, 16 (55 percent) did not find their work environment conducive to writing a good note, and eight (28 percent) said writing a good note was not important. Additionally, 14 residents (48 percent) reported receiving little to no feedback on note quality from senior residents and/or surgery attendings. Overall, 17 residents (58.6 percent) approved of the revised progress note template, while 11 (38 percent) were neutral and only 1 resident (3 percent) opposed it.

 

Discussion

The strategies and interventions used in our study demonstrated a quantitative and qualitative improvement in our surgical resident daily progress notes. It is unlikely that a single component of our approach resulted in the improvement of progress notes within our institution. Rather, we believe that it was our multidisciplinary approach, combining a significant restructuring of our resident progress note template with guiding the authors toward creating less-cluttered, focused documents that led to success in our quality improvement initiative. In addition, the steps taken to reach the aforementioned change are also worthy of discussion.

First, as an institution, it was necessary for us to recognize the importance of physician documentation. We then had to identify the relevant stakeholders who contributed to progress note generation: administration, surgery attendings and house staff. Through an iterative process and series of facilitated focus groups with the stakeholders, we were able to identify the elements that required change to improve the final progress note product. By identifying our working group as an entity of change and facilitating the larger group discussion, we were able to generate a larger sense of collective responsibility from all parties for improving physician documentation, generating a crucial component toward our improvement goal.

We encountered and resolved numerous important challenges throughout this project. First, we discovered that when our focus groups were presented with a broad, open-ended topic, the discussion often rapidly digressed away from our area of interest. As a counterstrategy, we simplified our sessions using focused, manageable questions, with the end points for the discussion clearly and explicitly stated at the beginning of the session.

One of our other significant challenges was ensuring our key stakeholders stayed enthusiastic for the project’s 15-month duration. In fact, sustaining enthusiasm was a substantial hurdle that frequently threatened to derail our project entirely. Because of the time required to re-engineer the progress note, we had a three- to four-month period of relative inactivity, a classic conundrum in project management science, contributing to a lack of engagement, enthusiasm and project inertia.

It became evident that simply mandating change was not a particularly effective way to enhance participation. Therefore, to re-engage our stakeholders when the redesigned template was released, we adopted the same multisession meeting strategy. This was critical in gaining widespread adoption of the progress note and engendering ownership of the new progress note by our involved parties.

One of the strengths of our project lies in the fact that it was a real-world study, making it applicable to clinicians in other institutions of similar scale, size and organizational structure. Other strengths include the focus on patient safety and quality, as well as the emphasis on repeated, iterative interactions with our end user: the bedside-practicing resident physician. In addition, we believe that the prominence of multiprofessional working groups was a key component to the success of our project.

There were several limitations to this study. First, we used a slightly modified version of the PDQI-9 instrument to gauge note quality. As detailed in our methods section, the decision to condense the PDQI-9 was made based primarily on the fact that these nonsubstantive changes to the tool would create a more relevant, focused and efficient metric instrument, being aware that doing so could potentially decrease the global validity of the results.  

TABLE 2: LESSONS LEARNED

1. Early stakeholder identification is critical for identifying “champions” within each group to facilitate discussion:

  • Medical staff
  • Administration
  • Information Technology

2. Project must be broken down into manageable stages:

  • Investigation/exploration
  • Identification
  • Intervention
  • Implementation
  • Evaluation

3. Establish quality metrics specific to area of interest (e.g., progress note quality).

4. Work with stakeholders to transform their vague feedback and concerns into granular quantitative or semi-quantitative articulate discussion points.

5. Be receptive to feedback from stakeholders at each stage of project and continually update to retain stakeholder interest.

A second limitation was the fact that we used a single reviewer, a member of the study team, to grade all notes. This was done because of our limited human resources for this project. A third limitation was the sample size (60 notes evaluated). Considering that this was a pilot project, and the total number of residents was also small (29 residents), we felt that this sample size was appropriate. Fourth, we did not assess the inter-reviewer reliability of our PDQI-9m instrument. Moving forward, larger studies would mandate reliability and validity testing of this instrument to confirm its generalizability. Finally, though there is a theoretical concern for replacing discrete, structured data with free-text, unstructured data, recent studies have suggested that the overall benefits of improved communication with narrative sections outweigh any potential downsides of removing structured data elements.5,13

In this article, we have demonstrated one potential approach to improve the quality of surgery resident physician documentation. As has been demonstrated in similar published projects, attempts to improve the quality of EHR physician progress notes in an academic medical center are not for the faint of heart.11,14 In our large academic teaching hospital, a multimodal approach of strong and organized physician leadership, clear vision and resilience in management appears to be one path toward improved outcomes in this challenging area of health care. Future directions include validating the PDQI-9m instrument and expanding this project to other departments within our medical center using the lessons learned from these initial efforts.

Prerna Panjikar, MD, is a research physician at New York-based Maimonides Medical Center.

Joshua K. Ramjist, MD, MSc, MBA, is a chief resident in the surgery department at New York-based Maimonides Medical Center.

Alex Abdurakhmanov, MD, is a resident in the surgery department at New York-based Maimonides Medical Center.

Ronald N. Kaleya, MD, FACS, is the chief of gastrointestinal oncology at New York-based Maimonides Medical Center.

Zachary Lockerman, MD, MBA, CPE, FACG, is the chief medical informatics officer at New York-based Maimonides Medical Center.

Richard H. Savel, MD, CPE, FCCM, is the director of adult critical care services at New York-based Maimonides Medical Center. He also is a professor of clinical medicine and neurology at the State University of New York’s Downstate College of Medicine.

REFERENCES

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