Published in the February 2017 issue of Today’s Hospitalist
WE’VE ALL GONE THROUGH RESIDENCY, so we know how overtaxed and frustrated residents can feel as they work to develop patient-care skills, particularly their first year.
But as a medical educator, I feel we need to train residents simultaneously in another set of skills: electronic clinical documentation.
In a survey published in the October 2011 issue of Academic Medicine, residents identified documentation as one of the most frequent skills they used during their first month of residency—but one that had the least amount of attending supervision.
If documentation was a procedural skill, that lack of oversight would be very concerning. Complicating the situation in the era of value-based care: Our electronic documentation is increasingly being scrutinized to make sure it demonstrates high-quality, patient-centered and efficient care.
Doctors buy into training a lot more when it’s delivered by a fellow clinician.
As I work to build a comprehensive curriculum, here are some thoughts on what that may look like and on how we should be using all kinds of opportunities—from clinical documentation queries to training at the point of care—to improve residents’ documentation skills.
As an academic internist practicing hospital medicine, I’ve taken on the mission of enhancing education in clinical documentation for both our medical students and residents. Fortunately, a growing amount of national attention is being paid to how to document effectively in an EHR. At my own institution, documentation is increasingly recognized as being both “skillable”—teachable skills that can be learned and practiced—and important to clinical care and patient safety.
Moving beyond lectures
Our current program to train residents in documentation is evolving. Previously, that curriculum consisted of only one or two hours of lectures, often delivered by non-clinicians.
But according to literature in medical education, isolated didactic lectures are of limited value and are unlikely to result in learners acquiring skills. We also need to acknowledge that clinical documentation requires collaboration and a multidisciplinary approach between clinician-educators and leaders in clinical documentation improvement (CDI), as well as others.
The curriculum that I have been collaborating with our CDI team to develop emphasizes repetition in specific content and skills.
We plan to present case-based modules during internal medicine morning report, one every six to eight weeks. Each module will emphasize only one or two key learning points in clinical documentation, and I will deliver these sessions along with our CDI leaders.
The seminars will cover high-impact areas pegged to real-time documentation lapses. We will zero in on documentation opportunities not only for diagnostic clarification, but to highlight important areas such as how to document patient safety indicators, complications of hospitalization, diagnoses present on arrival and hospital-acquired conditions. Another area of focus will include documentation to demonstrate medical necessity.
We also have committees that have created our own clinical definitions for diagnoses that are vague in terms of concrete clinical indicators, such as anemia and respiratory failure. We may include modules in this case-based series to provide training on how to document those areas as well.
Interactive learning
I see these sessions as being panel discussions, with residents as the audience. But we need to acknowledge that this current generation of residents and students learns through advanced technological and interactive modalities.
As a result, we are exploring other platforms to introduce key content and skills that residents can use before and after the case-based sessions. This approach demonstrates the concept of the “flipped classroom,” in which learners look at explanatory material on their own time, then spend class time in exercises or discussions.
Other possible methods are independent learning and the use of games. I am working with our medical school’s instructional design team to build such asynchronous tools.
Our goal with this curriculum is to deliver key content and foster skill acquisition through “deliberate practice,” whereby learners repetitively practice a skill and receive feedback. That approach takes into account not only the quantity of practice needed to develop skills, but the quality as well.
When should we present such a series? For first-year residents, I’d say after about six months, giving them time to concentrate on developing their clinical skills.
Collaborating with CDI
Who should be involved in such training is also a big consideration. It’s no secret that doctors buy into training a lot more when it’s delivered by a fellow clinician. We need to engage physician champions as well as faculty and residency program leaders, but I also want to emphasize the role of CDI leaders.
Beyond developing the new curriculum, our CDI department has already optimized point-of-care collaboration between our residents and CDI specialists. In our hospital, CDI specialists are staffed to specific service lines. The nonteaching hospitalist service, for instance, has a dedicated CDI specialist, as do our academic teaching teams.
As a result, residents in each service become very familiar with these specialists and learn that they are integral members of the multidisciplinary team.
Additionally, as part of residents’ orientation to various inpatient services, CDI specialists distribute laminated pocket cards that the residents carry. Those cards spell out high-yield documentation pearls specific to clinical documentation on that service.
CDI specialists also send residents a series of emails with documentation tips covering topics that frequently lead to queries. And for residents, the queries themselves represent important teaching opportunities.
It helps that we have a standard process in place for providing clarification on queries: If an intern doesn’t respond quickly, the query is kicked up to the upper-level resident and then on to an attending.
At the point of care, it’s also important that attendings use their attestations to improve residents’ documentation. Increasingly, our faculty physicians consistently provide independent documentation that captures the complexity and intensity of care.
The impact on patient care
I believe we all benefit by improving residents’ documentation skills.
By doing so, we are teaching them that high-level documentation improves clinical care and patient safety. They learn that consistent, effective documentation enhances better care transitions and communication between clinicians, and that doctors who document with a high degree of precision give their colleagues a much richer, more accurate clinical picture.
We’re also teaching residents that documenting patient acuity and complexity better informs our expected hospital outcomes. And if we don’t train residents in clinical documentation, we aren’t preparing them to be accountable for the metrics that will be used to measure their performance, once they’re in independent practice.
To help motivate them to learn, I make the case that better documentation helps them avoid the “copy forward” and cloning problems we see in electronic documentation. I also stress that highly specific documentation enhances biomedical science, quality, written communication, revenue and professionalism.
Joseph A. Cristiano, MD, is a hospitalist at Wake Forest Baptist Medical Center in Winston-Salem, N.C., and an assistant professor at Wake Forest School of Medicine. Dr. Cristiano has been involved in improving medical education around clinical documentation for four years.
