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Rethinking Clinical Documentation

Posted Apr 05 2010 3:00am
Over the past 5 years, I worked with HITSP and the HIT Standards Committee to select standards for exchanging clinical summaries. But what exactly is a clinical summary?

There is common agreement about the need to exchange codified, structured data for problem lists, medications, allergies, and labs.

However, what is the role of unstructured clinical documentation text?

Some have suggested that unstructured text is hard to navigate, at times repetitious, and challenging for computers to interpret.

I believe the exchange of free text notes such as operative reports, history&physicals, ED charts, consult notes, and discharge summaries is very important.

Consider this example.

A 40 year male with no family history of heart disease presents to the ED at 3am with a chief complaint of chest pain and left arm numbness. The EKG is normal, a stress test is normal, labs are normal, and a cardiology consult is completed. The patient is discharged on H2 blockers with a diagnosis of gastritis.

A summary which only includes a problem and med list may state a Problem List of Gastritis and a Medication List of Prilosec OTC.

When the patient next visits an Emergency Department, no one will know about the cardiology consult, the differential diagnosis considered, and the thought process that led to the diagnosis of gastritis to explain the chest pain.

An entire workup will be started from scratch.

There is a great article in the March 25, 2010 of the New England Journal of Medicine "Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?" by Gordon D. Schiff, M.D., and David W. Bates, M.D. in which the authors note:

"Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient's history and making assessments, and notes should be designed to include discussion of uncertainties."

I agree.

Notes should be included as part of clinical summaries.

However, we should do all we can to improve the quality of notes.

Over the next year, we hope to try a radically different approach to clinical documentation at BIDMC which we think will leverage all the strengths of the full text note as described by Drs. Schiff and Bates without the repetition and navigation issues.

Today's inpatient charges are a collection of SOAP notes written by the medical student, intern, resident, fellow, attending, and consultants largely for billing and medico-legal purposes.

What if the chart was recast as a communication vehicle for the entire team that summarized the day's events and collective wisdom on next steps?

Our answer - a daily Wiki entry for each patient authored by the entire team and signed/locked by the attending at the end of each day.

How will this work?

Think of it as a private wikipedia build inside our clinical systems and hosted in our data center.

Each member of the care team will use our Team Census application to view the list of patients for whom the team is responsible.

Clicking on any patient name will bring up the daily Wiki. Each member can add documentation, revise existing text, and leverage the work of others on the team until the attending makes the final edits and signs/locks the day's documentation. Just like a wiki, a complete journal shows all all edits/changes/deletes, so no information is lost. Importantly the day's wiki entry has one physical exam, one assessment, and one plan - not 17 repetitive entries saying the same thing that often appears in today's paper charts.

The idea of a daily wiki entry for each patient creates highly readable succinct documentation authored by the entire team with a medical legal record of the process that was used to generate it. It's a perfect single document to share with the referring clinician and the patient/patient's family.

After our initial pilot work, I'm guessing we'll also engage the patient and families to add to the Wiki, reflecting the shared decision making between the team, the patient, and the patient's family.

We're in the design stage now, but I'll report back on how it goes.

A daily patient Wiki as unified clinical documentation, exchanged with the team, other providers, and the patient. I bet even the free-text naysayers will agree that this should be part of the clinical summary!
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