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Note bloat: problems with cut and paste

Do electronic shortcuts make you sloppy?

March 2020
note bloat cover

AS MEDICAL DIRECTOR of the hospitalist program at Aspirus Wausau Hospital in Wausau, Wis., Steven Phillipson, MD, has long known that note bloat and cloned notes are big problems for physicians, no matter their specialty. But those facts of electronic life have taken on new urgency in his part-time role as a physician advisor.

“When you’re focused on reviewing charts, you see just how much is copied and pasted,” Dr. Phillipson says. “And payers, of course, pick up on that right away.” That can lead to denials, as well as increased liability for physicians and hospitals.

As a result, Aspirus is beginning to hammer out a health system policy on cut and paste. Dr. Phillipson expects to hold a day and a half of meetings with providers to assess the risks of cut and paste to patients and the health system. Once that assessment is made, he’ll bring staff from utilization review and the compliance office along with medical executive team members on board.

“Everybody knows which doctor’s notes can or can’t be trusted.”

Stella Fitzgibbons

~ Stella Fitzgibbons, MD

“There are probably some good ways to do copy and paste and then some not-so-good ways,” says Dr. Phillipson. While he and his colleagues don’t at all contemplate “turning off the copy and paste function in its entirety,” he does expect to come up with some ground rules. “What can people do, and what shouldn’t they be doing?”

Problems with electronic tools—copy and paste, copy forward, overuse of autofill and smart phrases, pre-made templates with drop-down menus that doctors can and do speed through—are a definite unintended consequence of electronic documentation. According to all accounts, the problems seem to be getting worse.

An August 2017 study in JAMA Internal Medicine found that only 18% of the inpatient progress notes analyzed were manually entered, with the rest either copied or imported. Other research indicates that while a majority of doctors appreciate the potential hazards of misusing electronic shortcuts, an even bigger majority keeps using them.While only a few places are considering policies to potentially restrict some copying functions, others are relying on new technological tools to tamp down excesses. All the while, doctors continue to debate how comprehensive their daily notes should be. And they worry about limiting tools designed to lighten a heavy documentation load.

“Loafer doctors”
As an expert witness, hospitalist Stella Fitzgibbons, MD, sees “only isolated cases” that are lost in court due to copied and pasted notes. However, she sees plenty of copy and paste in her clinical practice in Houston.

“There are probably some good ways to do copy and paste and then some not-so-good ways.”

Steven Phillipson, MD

~ Steven Phillipson, MD
Aspirus Wausau Hospital

“A consultant whose report begins with the first three sentences of my H&P makes me wonder how much I need his help,” she says. “It also makes me wonder if that doctor was ever in the patient’s room.” She also notices when nursing notes reflect a new problem “that a doctor’s unchanging notes never mention.” She herself steers clear of copy and paste in her documentation unless she needs to reproduce an imaging report or operative note. But, she admits, “I’m in the minority.”

Fortunately, Dr. Fitzgibbons points out, patients are often seen by two or three different hospitalists during a stay. While such handoffs are considered a major downside of hospital medicine, she believes they boost the odds of having an accurate chart, assuming that at least some of those doctors take pains to keep their notes updated. “Everybody knows,” she says, “which doctor’s notes can or can’t be trusted.”

Cedric Edwards, MD, agrees. An independent hospitalist working at community hospitals mostly throughout Mississippi, Dr. Edwards finds a few people in every hospital who “abuse the system,” cloning notes they don’t bother to read or refresh.

Often, he points out, the culprits are specialists, particularly proceduralists who just don’t put time or effort into documentation. Or the issue is what he calls “loafer doctors. They always want to leave the hospital very early, so they do their job halfway. They don’t just slack on their notes but on patient care in general.”

Advocating for shortcuts
That said, Dr. Edwards is a big advocate of electronic shortcuts that cut his time on the computer. He always clones his previous day’s note, then meticulously updates with new information, deletes what’s been resolved or changed, and refreshes his daily assessment. He’s a total fan of copy forward, autofill and smart phrases, and he makes liberal use of them all.

“A really slow EHR? I won’t take the job.”

~ Cedric Edwards, MD

~ Cedric Edwards, MD

In fact, the speed and efficiency of a hospital’s EHR is a key factor he considers before deciding to work in a new hospital. Before he signs on, Dr. Edwards asks about the typical daily census; whether the hospital expects him to do procedures, run codes, or cover the ICU; and what type of EHR the hospital has.

Without a fast EHR with plenty of efficiency tools, Dr. Edwards says he would be overwhelmed doing documentation in community hospitals where the daily census can top 20 patient encounters. A fast EHR can cut the time he spends documenting almost in half.

But “if there are a lot of admissions and rounding and I need to do procedures, run codes and cover the ICU with a really slow EHR?” he says. “I won’t take the job.”

Building templates locally
At University of California, San Diego (UCSD), hospitalist Joseph Avalos, MD, is devoting most of his time for quality improvement this academic year to improving the accuracy and brevity of resident documentation.

So far, he and the residents have produced a new progress note template, “very simplified SOAP notes that eliminated a lot of the fancy tricks and excess autofill and smart phrases that Epic can provide,” Dr. Avalos says. Because the UCSD residents also work at the local VA hospital, he and his team kept the VA’s template in mind when designing their own, “to be consistent. It’s important to build a template locally to come up with something that’s usable and that doctors will buy into.”

“Residents are basically creating perpetual discharge summaries, and the end result is a laundry list.”

Joseph Avalos, MD

~ Joseph Avalos, MD
University of California, San Diego

Dr. Avalos also crafted a pocket guide now used by all staff that lists note-bloat reduction tactics. He is also putting together educational sessions and workshops for residents on how to write more concise notes.

And he is instituting regular feedback. “I’ve asked my attending colleagues to go over one note each week with their team, giving them formal feedback on it just as they would clinical evaluation feedback,” Dr. Avalos says. “I’ve asked them to say, ‘This part is good and this part could be improved.’ ” The hope with attendings, he adds, is to improve their documentation through leading by example.

Include the whole story?
The biggest problem that Dr. Avalos sees is what he calls “stacking,” where residents tack on to each day’s note the entire list of problems—and labs and images—of what’s happened since admission.

Part of the problem is residents’ mistaken belief that “if I don’t have it in the note, it may look like I didn’t address it,” he says. Another factor: Residents don’t receive enough education about the difference between the daily note and the discharge summary.

“The progress note should reflect only the clinical thought process of today,” he points out. “The discharge summary is for the clinical thought process of the whole hospitalization. The residents are basically creating perpetual discharge summaries, and the end result is a laundry list.”

But that reflects a larger difference of opinion among physicians, says hospitalist Julie Hollberg, MD, chief medical information officer for Emory Healthcare in Atlanta. Dr. Hollberg points to what she sees as an evolution in how physicians both write notes and read them.

“Notes have gotten longer to include the entire story of the hospitalization.”

Julie Hollberg, MD

~ Julie Hollberg, MD
Emory Healthcare

“There’s now a debate about whether a note should contain a patient’s entire history to that day or whether you should write only short notes with that day’s occurrences,” she says. Back when hospitalists relied on paper charts, “we’d frequently read, say, the last 10 short notes to get the gist of what was going on with a patient we were seeing for the first time.”

That no longer happens, she explains, and doctors no longer expect to read previous notes. Instead, “people now expect that everything will be in the most recent note,” a justification for doctors to copy information forward. “While each note may add a new chapter, notes have gotten longer to include the entire story of the hospitalization.”

Dr. Hollberg does her own subjective and objective sections “from scratch” every day, but she does copy and paste her previous day’s assessment and plan, then edits them. And “I like to tell the story in my notes,” she says, “but I try to be brief as I am doing it.”

That stylistic change, not a lapse in professionalism, is part of the reason why notes have gotten longer. That’s also why Dr. Hollberg believes it’s difficult to come up with ground rules on electronic shortcuts. “There’s not necessarily a clear decision on which approach is right or wrong, as long as the note is accurate.”

A matter of trust
Daniel Kahn, MD, a hospitalist at UCLA Medical Center in Los Angeles, also devotes a lot of effort to figuring out how to encourage more concise notes.

He was the lead author of a June 2018 study in the Journal of Hospital Medicine, one that tested the use of a new progress note template along with educational sessions among residents at four academic centers. (UCSD was one of those centers.) Use of the new template led to more relevant notes that were 25% shorter—and were completed 1.3 hours sooner.

“By actively writing the note, it makes you cognitively review what is going on with a patient.”

Daniel Kahn, MD

~ Daniel Kahn, MD
UCLA Medical Center

Dr. Kahn says he’s gratified to see that UCLA’s current residents are still using the template he helped draft, or one that’s very similar. But he also points to this trend: “Over time, items have been added to the template” to help assess quality measures and improve patient care. Such additions “have led to introducing more clicks,” which in turn affect a template’s “usability and uptake.”

Dr. Kahn agrees that electronic documentation has driven an evolution in how physicians read and complete notes. With features that can perpetuate inaccuracies, “there is an awareness that electronic health record notes might not be 100% accurate.” Physical exam findings have particularly taken a hit.

“I think the physical exam is not always trusted in a progress note anymore,” says Dr. Kahn. “There is a risk with copy forward where the physical exam section may not reflect how the patient looks each day.” The good news is that awareness of this risk leads many doctors “to pay extra attention to keep their note updated.”

But given the time crunch doctors are under and how bloated notes can be, “a lot of the note is just not read,” he says. “People skip to what is thought of as the most important part of the note: the assessment and plan.”

Active writing and cognition
One key finding in his 2018 study, says Dr. Kahn, is that less use of so-called “efficiency tools” resulted in notes being completed on average earlier in the day. The template encouraged users to enter free-text data via prompts (“Pertinent labs include … “) rather than simply autopopulating the note.

“By limiting the use of an ‘efficiency’ tool like autopopulate, we found that the notewriting process actually became more efficient,” he says.

And prompts for free-text data enhance what Dr. Kahn believes is a critical function of documentation.

“The note has multiple functions including communicating to other team members and consultants,” he points out. “But I think the most important aspect is that, by actively writing the note, it makes you cognitively review what is going on with a patient.” That can lead physicians to consider issues they may not have thought about before they sat down to document. “The more you passively populate your note with data, the greater the risk that you may miss something.”

Help through software
While functions like autopopulate may sabotage the efficiency they were designed to create, physicians are using other electronic tools to stay on top of what’s been copied and pasted.

In both his clinical work and his role as physician advisor, Dr. Phillipson at Aspirus regularly uses a feature that was part of Epic’s software update a few years ago: the copy-text feature. That allows him to hover over note text and see what’s been copied.

“Different sections light up with different shades for copy and paste, what’s been templated and what are new thoughts,” he points out.

Dr. Avalos at UCSD—which also uses Epic—likewise uses that feature. His group is also piloting a new Epic feature that’s not yet formally available; he and his colleagues refer to it as “whisper text.”

When turned on, the feature gives short recommendations within the template to, among other things, “refresh, review and edit all components. We can put in reminders to ourselves on what to include and what not to.” The whisper text reminds people to avoid putting in the last three days of labs or images and to instead record only their interpretations.

Once the note is finished, that guided text disappears. “We think it’s wonderful,” says Dr. Avalos. “We’re hoping to incorporate it into discharge summaries and documentation for outside hospital transfers.”

At Emory, Dr. Hollberg and her colleagues use Cerner—and many of them use software called Dynamic Documentation, which was part of a 2015 upgrade. That software allows physicians to copy and paste pieces from the previous record to build notes, but it doesn’t have the automatic copy and paste feature of their older documentation tool.

Concern about note bloat was part of Cerner’s rationale for limiting that, says Dr. Hollberg. Physicians who have come on board at Emory since 2015 are encouraged to use the newer software.

But Dr. Hollberg points out that many doctors still use the EHR’s older documentation software. She says the older version—in addition to permitting full copy and paste—also includes a better ability to mine data and a better discharge summary template. A review of notes completed this January found that 54% of physicians used the newer note template, while the rest stuck with the older one.

Does Emory plan to mandate use of the newer software? Not at all, says Dr. Hollberg. “It’s just a matter of personal preference.”

Efficiency vs. burnout
At the end of the academic year at UCSD, Dr. Avalos says he will measure how much residents have used the new template and see if their notes have gotten more concise. He believes, however, that broad adoption of the template will take culture change. In academics, that can mean a cycle of three or four years.

“We’re educating interns one year and then teaching them again each year as residents,” he says. “As new interns come on, they’ll eventually see that senior residents are using better progress note-writing techniques.”

Emory’s Dr. Hollberg also believes that the long-term solution to note bloat is a culture of medical professionalism.

Electronic tools that encourage certain types of documenting behavior can help, she notes. But “we have a major problem with physician and APP burnout that we need to tackle. Until we do, we have to be really careful about making any major changes that affect provider efficiency.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Published in the March 2020 issue of Today’s Hospitalist

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Gerardo Guerra Bonilla, MD
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Excellent article. Medical documentation should only have three purposes: continuity of care, billing and legal coverage. The rest is note bloat and only contributes to long hours in front of the computer and physician burnout. I don’t think there’s anything wrong with wanting to get out of the hospital or clinic on time to be able to have a normal work-life balance. The medical documentation problem is bad enough that now there is a term for finishing your notes at home: “pajama time.” Everyone will tell you copy-paste is not ok. I like the term “copy forward.” As long as… Read more »