November 21, 2011

The Hazards of Note Bloat
By Cassi L. Birnbaum, MS, RHIA, CPHQ
For The Record
Vol. 23 No. 21 P. 14

Proven prevention strategies can help keep EHR documentation slim and trim.

Rady Children’s Hospital of San Diego, which began its EHR journey in early 2000 when it went paperless on the back end, learned many lessons along the way, not the least of which was the value of first-rate documentation.

While converting to an electronic system, the 442-bed pediatric facility discovered that notes in its niche neonatology documentation system quickly built on the next one and replicated artifact detracted from new information. As a result, it didn’t take long before the notes became unreadable to other physicians.

It became difficult to distinguish new clinical data from documentation that may be describing a condition from a day, a week, or a month ago. Although the neonatologists felt the system saved them time, other physicians found their notes to be unhelpful. This example illustrates the need for relevant, timely, accurate, and succinct documentation in the EHR. Clinicians must be assured that the note reflects how sick the patient actually is.

Research Findings
In an article published in the June 2009 issue of The American Journal of Medicine, Eugenia L. Siegler, MD, and Ronald Adelman, MD, identified hazards in electronic documentation that can lead to reduced credibility of recorded findings, clouding clinical thinking, limiting proper coding, and robbing the chart of its narrative flow and function. They also pointed out that problem lists never change.

The authors said staff members recognize that if they organize problems by system, they can copy and paste the same problem list day after day even if new diagnoses appear or priorities change. When updated information is added, it is difficult to view, and notes lengthen and errors accumulate.

A study featured in the July-August 2004 issue of the Journal of the American Medical Informatics Association measured the impact of computerized physician documentation at a teaching hospital. The authors, who interviewed resident physicians and faculty, identified the following three problem areas:

• Redundancy: The same information and misinformation was repeated. It was also difficult to identify where the misinformation began.

• Formatting: Staff had trouble segregating useful information—”stuff you care about”—from meaningless data in the endless notes.

• Decreased confidence in the material: One person interviewed said the progress notes made it appear that the same physical exam was performed by an intern, a resident, an attending physician, and a subspecialist.

Getting It Right
In 2010, Rady Children’s undertook a research project to determine how it could avoid the problems associated with note bloat. Literature on how best to maintain clinical data integrity, including the AHIMA tool kits associated with documentation integrity best practices, was reviewed. In addition, HIM participated in the hospital’s EHR Practice Council, and major EHR systems were analyzed to determine the circumstances that led to the creation of well-written notes free of extraneous, repetitive documentation.

In collaboration with the Health Information Physician Advisory Council, HIM developed a set of documentation guidelines covering various topics. Strategies were then devised to facilitate the creation of original documentation and eliminate redundant content.

Technology solutions that enable the patient’s story to be told through the use of a narrative, free-form text field populated by either direct typing or through the use of speech recognition were also discussed. Although conventional dictation at Rady Children’s has been greatly reduced since the adoption of its EHR, it was felt that it couldn’t be entirely eliminated because of the complex care received by many of its patients. Therefore, reports and conditions warranting continued dictation or speech recognition were identified.

The hospital is in the final stages of testing a speech recognition solution that features historical voice profiles and utilizes voice or keystroke commands to navigate to various places in the EHR to fulfill content requirements. The initiative, which is in the process of selecting phase 1 users, is scheduled to go live in December.

EHR Design
Under the guidance of Chief Medical Information Officer Cynthia Kuelbs, MD, the hospital reviewed recommendations set forth during the 2003 American Medical Informatics Association symposium. “Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting and Duplication” proposed that institutions using EHRs should do the following:

• reengineer templates to avoid unnecessary duplication artifact;

• minimize inserting patient data available elsewhere into the narrative record;

• develop medical history and examination data objects that can be reviewed, amended, and reused;

• enhance the problem list function as a better alternative to copying text lists;

• enhance automated methods to more efficiently monitor for dangerous and misleading copying (redundant content);

• caution clinical departments against excessive use of copying (redundant copying) to boost productivity;

• teach practitioners and students that careless copying (redundant copying) creates untrustworthy records; and

• empower teachers to monitor the writings of trainees with automated methods.

Strategies to prevent note bloat were incorporated into all aspects of EHR design, build, and training to lessen the need to insert documentation already available either in current or previous encounters. The experience gained from implementing an EHR in the spring of 2008 and going live the following year enabled the inpatient clinical content build team to draw from a rich background of lessons learned to rein in the use of irrelevant documentation to ensure purposeful, meaningful content.

One key maneuver that paid immediate dividends was the insertion of discrete data field content into the documentation template, which had the added benefit of reducing a provider’s need to populate these elements. This approach was first designed for the EHR clinical application in the emergency department (ED) when it was found that numerous elements were being replicated or entered unnecessarily. Not only were ED doctors affected, but the length of reports also impacted document distribution to primary care physicians.

Elements brought forward for the creation of a report (print group) included discharge disposition, diagnosis if a current problem list was populated, follow-up instructions, and allergies and adverse reactions reviewed and verified by the physician. This tactic was also invoked for the creation of discharge summaries, operative reports, and some elements of the history and physical exam in the inpatient environment.

Specific workgroups were established to deal with some of the most problematic aspects of the EHR and tackle requirements associated with Rady Children’s key initiatives, including meaningful use, clinical documentation improvement (CDI), and mitigation strategy associated with the transition to ICD-10. A key focus was maintaining the integrity of the problem list to ensure only relevant problems are catalogued going forward and that all current hospital problems, including the designation of a principal problem, are chosen. This assists not only the CDI specialists, but also minimizes the duplication of diagnostic information in the EHR. Documentation can then be repurposed in other key reports as required.

A team composed of clinical and HIM informaticists, CDI medical director Nicholas Holmes, MD, and HIM leadership developed an approach and implemented preference lists by specialty to address some of the data integrity challenges associated with the lengthy lists emanating from the current SNOMED mapping to ICD-9 niche vendor system. To address the challenges of transitioning to ICD-10, CDI leadership is working with a vendor to develop an enhanced methodology to facilitate the selection of the most specific diagnoses.

Additionally, the problem list is a continuing care documentation element that moves with the patient across the continuum in a health information exchange environment, of which Rady Children’s is an active participant through its vendor-sponsored EHR, CareEverywhere, and its association with the San Diego Beacon Community.

Organization Awareness
Education on the hazards of redundant documentation and bloated notes has been formally inserted into Rady Children’s enterprisewide physician education program. Providers also receive informal feedback through a variety of methods and forums. The CDI review process facilitates timely communication between providers, CDI specialists, and Holmes to ensure accurate, timely, relevant, and meaningful documentation.

“Note bloat is a natural phenomenon as the physician transitions from the paper world to electronic. As part of the change process, a physician has some fear the patient’s story is going to be lost in the electronic world. Thus, the physician feels obligated to include all data at every patient encounter,” says Holmes, a pediatric urologist. “Extensive end-user education on the EHR and physician ease or comfort with the system are the best way to stem the tide against the note bloat phenomenon.”

Although there is not a perfect system or tool to prevent note bloat, Rady Children’s has created a best practice model from which other organizations can carefully construct their documentation programs to prevent unreadable notes. Its motto, “It’s for the Kids,” is imbedded in everything associated with the EHR rollout and its continued optimization. The prevention of note bloat ties back to the hospital’s mission to ensure that documentation in the EHR serves as a useful tool to support the care and treatment of its patients across the continuum of care.

— Cassi L. Birnbaum, MS, RHIA, CPHQ, is the director of health information and the privacy officer at Rady Children’s Hospital in San Diego.