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Drowning in note bloat?

October 2014

ONE THING you have to give to electronic health records (EHRs): They’ve made physician notes legible. Unfortunately, they’ve also allowed doctors to produce a staggering amount of auto-generated data that can render physician notes close to useless. As such, note bloat and other electronic documentation hazards “like copy and paste, and copy forward ” threaten both patient safety and physician liability.

That’s according to Manoj Ramachandran, MD, medical director for clinical documentation integrity and coding at Carilion Clinic in Roanoke, Va.

“The idea is to have your whole note in one screen.”


~ Manoj Ramachandran, MD
Carilion Clinic

Take the patient with a previous mitral regurgitation and systolic murmur, whose physicians “using an electronic template “mistakenly documented a normal cardiac examination, an error carried through to the discharge summary. Two months later, when the patient was readmitted for bacteremia and sepsis, doctors concluded that the murmur was new and that it required transesophageal echocardiogram to further evaluate for infective endocarditis.

Or consider the documentation shortcuts that can save time but also lead to real trouble. Because Carilion Clinic has used an Epic EHR since 2008, Dr. Ramachandran is proficient in Epic smart phrases (also known as “dot phrases”), which insert data or text into a note, as well as smart links, which display or pull data directly from the patient’s chart, and smart lists, which let you choose one or more predefined options.

One helpful Epic smart phrase is “.HPROBL,” which doctors use to reproduce a patient’s list of active hospital problems. “When I started working here, every hospitalist used this smart phrase in their template,” Dr. Ramachandran says. “But it is seldom updated after admission. It often shows hypotension as a problem, even though the plan indicates that the patient is currently on three antihypertensive medications.”

NOTE BLOAT: problems with cut and paste

Even when doctors don’t misuse smart phrases, traditional progress notes written in SOAP format (subjective, objective, assessment and plan) let the assessment and plan portions sink under the weight of ECHO and imaging results, three days’ worth of labs, and vital signs for the last 24 or 48 hours.

“It’s sometimes impossible to figure out what’s relevant and what’s not,” Dr. Ramachandran says. “Most physicians don’t know the dangers behind note bloat because they don’t read their own notes.”

Those were the challenges facing Dr. Ramachandran and his colleagues on Carilion Clinic’s copy and paste committee, which was founded earlier this year. While they haven’t yet found a silver bullet to kill off note bloat and cloning once and for all, they are figuring out ways to rein in some electronic excess.

Upending the SOAP format
The first step, says Dr. Ramachandran, was to redesign the progress note because that note is used to create discharge summaries. The new progress-note template begins with a summary, giving physicians space to summarize in a few words why the patient was admitted.

A bundled intervention focuses on combating note bloat through a new progress note template

Currently, Dr. Ramachandran is trying to popularize the progress notes in an APSO format by giving primary placement in the template to the assessment and plan.

“If I’m looking at a patient cared for by another physician, what I’m reading mostly would be the assessment and plan,” he says. “If, because of habit, you want to complete the subjective and objective portions first, no one prevents you from doing so.”

The new template deliberately eliminates the auto-population of the problem list, which usually occupies the assessment portion. This prompts doctors to think about the problems actually being addressed that day.

Dr. Ramachandran also encourages physicians to leave out unnecessary lab and imaging reports, and to steer clear of auto-populating the note with a medication list. When specific medications are relevant to patient care, “you can easily show them in your note using smart links.”

“I can always look at the labs somewhere else in the chart,” he points out. “If you think mentioning a particular medicine is important, include that in your assessment and plan.”

Instead, in the objective portion of the note, “I put in a line saying I reviewed all labs and imaging studies as of this date and that I reviewed all current inpatient medications and updated them,” says Dr. Ramachandran. Vital signs get one line in the physical exam portion of the note, with only the last set of vitals listed.

No need to scroll
The template designed by Dr. Ramachandran also gives physicians two options for documenting their physical examination.

They can either start with a complete negative examination by pressing Ctrl + F12. Or they can scroll through each system using F2 on the keyboard and correctly select the appropriate physical examination findings. This improves the accuracy of exam documentation and ensures compliance with billing guidelines. It also reminds physicians to visit the physical exam section before they sign the note.

“The idea is to have your whole note in one screen,” Dr. Ramachandran explains. Even when doctors decide to copy a note forward, “if the note itself is smaller, they’re more likely to go through it and less likely to propagate mistakes that could mislead physicians picking up the patient.”

He also encourages colleagues to combine the assessment and plan together. Hospitalists who are interested can access speech recognition software to help them with documentation.

About half the hospitalists are already using the new progress note template, and Dr. Ramachandran plans to approach other departments and tailor the template to their needs. With the new template, he estimates that he can now complete a progress note in half the amount of time it used to take, giving him more time for patient interaction.

Breaking the copy-paste habit
According to Dr. Ramachandran, the committee is also developing a copy-and-paste policy that will apply to all seven hospitals in the Carilion system. A December 2013 report from the HHS’ Office of Inspector General found that only 25% of surveyed hospitals had such policies.

He also notes that the medical center is about to go forward with a new version of Epic. He and his fellow committee members have explored the option of disabling the software’s copy-and-paste function, at least for some physician offenders.

“It turns out we can disable that function but only system-wide, not for individual people,” says Dr. Ramachandran. However, they expect that anything copied and pasted in the new version will be highlighted and labeled as such by the Epic software. That at least provides an audit trail, he points out, and may help physicians break the copy-and-paste habit.

Physician education about electronic documentation is also ongoing. Doctors can help themselves stay out of trouble by using the specific date instead of “today”, in their electronic notes, he says. When that “today” is copied forward for several days, “it’s very obvious that notes have been cloned.”

It also helps if physicians rely on smart phrases for dating purposes. Instead of free texting what a patient’s length of stay is in a particular note “which could be cloned if the note is copied forward, day after day “use the smart phrase (.LOS in Epic), for instance.

“That will automatically refresh the length of stay if the note is copied forward,” says Dr. Ramachandran. “More importantly, read your notes before you sign them.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Published in the October 2014 issue of Today’s Hospitalist