Uploaded by Stepzo Printers

Studying Documentation

advertisement
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/259207697
Studying Documentation
Article in Journal of Hospital Medicine · December 2013
DOI: 10.1002/jhm.2104 · Source: PubMed
CITATIONS
READS
0
809
1 author:
Daniel i Shine
University of Colorado
31 PUBLICATIONS 573 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
effect of adding modeled risk to real po[ulations and measuring O/E Mortality View project
All content following this page was uploaded by Daniel i Shine on 23 January 2018.
The user has requested enhancement of the downloaded file.
Journal of Hospital Medicine Journal
Copy of e-mail Notification
Your article (02104) from Journal of Hospital Medicine is available for download
Journal of Hospital Medicine Published by John Wiley & Sons, Inc.
Your article page proofs for JOURNAL OF HOSPITAL MEDICINE are ready for Review. John Wiley &
Sons has made this article available to you online for faster, more efficient editing. Please follow the
instructions below and you will be able to access a PDF version of your article as well as relevant
accompanying paperwork.
First, make sure you have a copy of Adobe Acrobat Reader software to read these files. This is free
software and is available for user downloading at http://www.adobe.com/products/acrobat/readstep.html.
Open your web browser, and enter the following web address:
http://115.111.50.156/jw/retrieval.aspx?pwd=e778c2233521
You will be prompted to log in, and asked for a password. Your login name will be your email address, and
your password will be --Login: your e-mail address
Password: e778c2233521
The site contains one file, containing:
-Annotated PDF Instructions
-Reprint Order Information
-A copy of your page proofs for your article
In order to speed the proofing process, we strongly encourage authors to correct proofs by annotating PDF files.
Please see the Instructions on the Annotation of PDF files included with your page proofs. Please take care to
answer all queries on the last page of the PDF proof; proofread any tables and equations carefully; and check that
any Greek characters (especially "mu") have converted correctly. Please check your figure legends carefully.
- answer all queries on the last page of the PDF proof
- proofread any tables and equations carefully
- check your figure(s) and legends for accuracy
Within 48 hours, please return via email to the address given below.
JHM Journal Production
E-mail: jrnlprod.JHM@cenveo.com
Journal of Hospital Medicine Journal
Copy of e-mail Notification
After returning your proofs to the Journal of Hospital Medicine, we strongly encourage you to approach your local
Press Relations office so that they can assess whether your publication is suitable for a press release. If your
institution chooses to prepare a press release, please have them contact the JHM production office
(jrnlprod.JHM@cenveo.com) to coordinate your efforts with JHM's embargo dates.
Technical problems? If you experience technical problems downloading your file or any other problem
with the website listed above, please contact Balaji/Sam (e-mail: wileycs@kwglobal.com, phone: +91 (44) 42058810 (ext.308)). Be sure to include your article number.
Questions regarding your article? Please don’t hesitate to contact jrnlprod.JHM@cenveo.com with any questions
about the article itself, or if you have trouble interpreting any of the questions listed at the end of your file.
REMEMBER TO INCLUDE YOUR ARTICLE NO. WITH ALL CORRESPONDENCE. This will help both of us
address your query most efficiently.
As this e-proofing system was designed to make the publishing process easier for everyone, we welcome any and
all feedback. Thanks for participating in our e-proofing system!
This e-proof is to be used only for the purpose of returning corrections to the publisher.
Sincerely,
Production Editor, JHM
E-mail: jrnlprod.JHM@cenveo.com
Additional reprint purchases
Should you wish to purchase additional copies of your article, please
click on the link and follow the instructions provided:
https://caesar.sheridan.com/reprints/redir.php?pub=10089&acro=JHM
Corresponding authors are invited to inform their co-authors of the
reprint options available.
Please note that regardless of the form in which they are acquired,
reprints should not be resold, nor further disseminated in electronic form,
nor deployed in part or in whole in any marketing, promotional or
educational contexts without authorization from Wiley. Permissions
requests should be directed to mail to: permissionsus@wiley.com
For information about ‘Pay-Per-View and Article Select’ click on the
following link: wileyonlinelibrary.com/aboutus/ppv-articleselect.html
USING e-ANNOTATION TOOLS FOR ELECTRONIC PROOF CORRECTION
Required software to e-Annotate PDFs: Adobe Acrobat Professional or Adobe Reader (version 8.0 or
above). (Note that this document uses screenshots from Adobe Reader X)
The latest version of Acrobat Reader can be downloaded for free at: http://get.adobe.com/reader/
Once you have Acrobat Reader open on your computer, click on the Comment tab at the right of the toolbar:
This will open up a panel down the right side of the document. The majority of
tools you will use for annotating your proof will be in the Annotations section,
pictured opposite. We’ve picked out some of these tools below:
1. Replace (Ins) Tool – for replacing text.
2. Strikethrough (Del) Tool – for deleting text.
Strikes a line through text and opens up a text
box where replacement text can be entered.
How to use it
Strikes a red line through text that is to be
deleted.
How to use it

Highlight a word or sentence.

Highlight a word or sentence.

Click on the Replace (Ins) icon in the Annotations
section.

Click on the Strikethrough (Del) icon in the
Annotations section.

Type the replacement text into the blue box that
appears.
3. Add note to text Tool – for highlighting a section
to be changed to bold or italic.
4. Add sticky note Tool – for making notes at
specific points in the text.
Highlights text in yellow and opens up a text
box where comments can be entered.
How to use it
Marks a point in the proof where a comment
needs to be highlighted.
How to use it

Highlight the relevant section of text.


Click on the Add note to text icon in the
Annotations section.
Click on the Add sticky note icon in the
Annotations section.

Click at the point in the proof where the comment
should be inserted.

Type the comment into the yellow box that
appears.

Type instruction on what should be changed
regarding the text into the yellow box that
appears.
USING e-ANNOTATION TOOLS FOR ELECTRONIC PROOF CORRECTION
5. Attach File Tool – for inserting large amounts of
text or replacement figures.
6. Add stamp Tool – for approving a proof if no
corrections are required.
Inserts an icon linking to the attached file in the
appropriate pace in the text.
How to use it
Inserts a selected stamp onto an appropriate
place in the proof.
How to use it

Click on the Attach File icon in the Annotations
section.

Click on the Add stamp icon in the Annotations
section.

Click on the proof to where you’d like the attached
file to be linked.


Select the file to be attached from your computer
or network.
Select the stamp you want to use. (The Approved
stamp is usually available directly in the menu that
appears).

Click on the proof where you’d like the stamp to
appear. (Where a proof is to be approved as it is,
this would normally be on the first page).

Select the colour and type of icon that will appear
in the proof. Click OK.
7. Drawing Markups Tools – for drawing shapes, lines and freeform
annotations on proofs and commenting on these marks.
Allows shapes, lines and freeform annotations to be drawn on proofs and for
comment to be made on these marks..
How to use it

Click on one of the shapes in the Drawing
Markups section.

Click on the proof at the relevant point and
draw the selected shape with the cursor.

To add a comment to the drawn shape,
move the cursor over the shape until an
arrowhead appears.

Double click on the shape and type any
text in the red box that appears.
For further information on how to annotate proofs, click on the Help menu to reveal a list of further options:
J_ID: JHM Customer A_ID: JHM2104 Cadmus Art: JHM2104 Ed. Ref. No.: 13-0322.R2 Date: 18-October-13
Stage:
Page: 1
EDITORIALS
Studying Documentation
Daniel Shine, MD*
Department of Medicine, New York University Langone Medical Center, New York, New York.
In 1968, Weed highlighted the importance of medical
documentation with his call for a single progress note
format.1,2 Since then, sweeping changes in the technology, purposes, and requirements of clinical record
keeping have fueled a steadily enlarging literature
devoted to the chart. Over the past half century
computers, lawsuits, regulations, and the use of documentation as a tool of billing have transformed the
hospital record. In addition, mounting pressure
to shorten inpatient stays, the vastly increased complexity of care, and a growing number of diagnostic
possibilities have combined to make medical documentation far more prolific and far less leisurely. All
these changes have stimulated a boom in documentation research coinciding productively with an era of
advances in the conduct of clinical trials and statistical
rigor. However, in important respects research into
medical documentation today is not asking the right
questions, either in the formulation of hypotheses or
in the choice of methodology. Forms of clinical communication that do not involve order sets or notes are
widespread, growing in sophistication, and increasingly relevant to new concepts of healthcare as a team
enterprise; documentation research has not embraced
this development. At the same time, methodologically,
the field suffers from a persistent professional bias in
the choice of research outcomes, a bias that limits the
interpretation of results by neglecting what happens
to the patient.
In assessing the chart as a communication device
and the effect of changes in documentation, it is
increasingly necessary to study direct interpersonal
communication as an alternative and partner to
writing notes. In particular, 3 recent developments
in healthcare emphasize the importance of broadening our concepts of clinical communication. First,
the need for discussion in the medical record has
become less pressing because of technical improvements in person-to-person communication. Second,
the electronic health record, by creating disciplinedefined “chart views,” has helped equalize the
stature of different healthcare disciplines but also
AQ1
*Address for correspondence and reprint requests: Daniel Shine, MD,
Department of Medicine, NYU Langone Medical Center, 550 First Avenue,
New York, NY 10016; Telephone: 917-855-5309; E-mail:
daniel.shine@nyumc.org
Received: September 23, 2013; Revised: October 1, 2013; Accepted:
October 2, 2013
2013 Society of Hospital Medicine DOI 10.1002/jhm.2104
Published online in Wiley Online Library (Wileyonlinelibrary.com).
An Official Publication of the Society of Hospital Medicine
fragmented the chart, making interdisciplinary
direct communication more necessary. Third,
changes in reimbursement are redefining medical
goals in such a way that only teams of healthcare
providers in close and constant personal communication can achieve them.
Rapid adoption of electronic health records has
encouraged researchers studying documentation or
information technology to focus on computer formats
as defining the range of possible communication strategies. And there is certainly a broad range of formats:
electronic progress notes may be free text or multiple
choice, typed or dictated, copy forwarded or composed daily, institutionally templated or selftemplated, furnished with or free from prompts and
pop-ups. However, it is not only, and perhaps not
even principally, the electronic record that has
changed how clinicians communicate with each other.
The technology of discussion over the last 2 decades
has become instant, utterly mobile, device independent, and capable of connecting all the patient’s caregivers at once to each other and to the medical record
in text, picture, and sound. That the same communications upheaval has visited practically every other
aspect of our lives diminishes perhaps the visibility of
this new virtual team in healthcare but not its
importance.
The electronic record certainly plays a role in
facilitating communication, through simultaneous
chart access and in many other ways, but even more
significant is the effect that computerization has had
on equalizing the roles of different disciplines and by
doing so in fragmenting the medical record. A computerized record expands and reorganizes “the
chart,” changing it from a single authoritative book
read by all to an almost limitless array of “chart
views” read by some. All viewers (patient, clinician
or researcher, administrator, reviewer or coder) can,
with equal claim to consulting the chart, categorize,
compare, combine, and format data elements from 1
or many encounters, whether inpatient or ambulatory. Typically, an electronic item of patient information may have several authors and many uses but
has no owner. Data are entered by protocol and in
different guises into many aspects of patient care as
components of notes, flow sheets, summaries,
pop-ups, and order sets unique to each of a number
of disciplines. As the electronic record equalizes but
also separates members of the healthcare team, interdisciplinary personal communication becomes more,
not less, important.
Journal of Hospital Medicine Vol 00 | No 00 | Month 2013
ID: komathi.k Time: 12:29 I Path: N:/3b2/JHM#/Vol00000/130100/APPFile/JW-JHM#130100
1
J_ID: JHM Customer A_ID: JHM2104 Cadmus Art: JHM2104 Ed. Ref. No.: 13-0322.R2 Date: 18-October-13
Shine
|
Page: 2
Studying Documentation
Recent and impending reimbursement reform
proves also to be a means of democratizing medical
care and enforcing better interdisciplinary communication. The basis for hospital reimbursement has evolved
over decades from day rates to payments for specific
diseases, a system under which profit margins are in
theory determined by the interdisciplinary efficiency
with which diseases are managed by all care givers
and the accuracy with which that management is
documented. The next, seemingly inexorable, step in
the evolution of reimbursement will result in further
democratization of care givers: a single combined
“disease episode” payment will be divided among all
those involved in a course of treatment that may span
many months and require many disciplines and many
types of intervention. Payment reform makes the
success of a visiting nurse as important to the cost of
a disease episode as the success of an orthopedic
surgeon, for if the visiting nurse does not do well the
patient will be readmitted or require more office
services. In this sense, payment reform, like the
electronic record, tends both to equalize the importance of different healthcare roles and to require their
enhanced communication.
As these changes in technology and reimbursement
evolve, the study of medical documentation must
increasingly address medical communication more generally. It is entirely possible, for example, that an individual daily progress note, whose preparation
consumes so many hours and removes caretakers from
patients, will no longer serve any demonstrable purpose.3,4 It may be that consensus summaries will prove
more useful in clarifying one’s own thinking and incorporating that of others than will a daily, solo chart
soliloquy in free or imported text. It is conceivable that
contrasting views will be best presented not as a debate
in the progress notes but as a plan mutually agreed
upon earlier in the decision-making process. These are
the kind of broader questions that investigators in medical documentation should be pursuing.
Another problem in studies of documentation is a
pervasive professional bias in the choice of end points.
Studies tend to evaluate documentary practices not by
their effect on patients but by their impact on physicians or nurses. Success is measured by clinician satisfaction, percent adoption, and note length or timing;
note quality is judged using a checklist derived from
professional surveys.5–15 End points like these will
often make 1 document look better than another in a
“results” section, but it is the relation between progress
notes and healthcare outcomes that determine whether
1 approach or another is of benefit to the patient.
For example, an important current debate is
whether free text adds essential nuance to a note or is
simply a nostalgic relic of the 3-ring binder.16–18 This
debate can be settled only if improvement with the
use or abolition of free text is measured in terms of
patient outcomes or resource consumption. Again, if
2
Stage:
An Official Publication of the Society of Hospital Medicine
it is important to know whether progress notes of a
particular length or structure create less handover confusion, then changes in medical error rates is a more
convincing way to evaluate this issue than a change in
physician opinion. It may be a good question whether
briefer notes will free nurses and doctors to spend
more time at the bedside, but along with measuring
bedside time that study should also ask about
improvement in reacting to important changes of clinical status. With today’s technology, group phone discussions could perhaps successfully replace examining
each other’s notes, but the measure of success should
be improved hospital efficiency or a decline in errors
and readmissions.
The questions we ask in our research today create
the treatments and policies of tomorrow. Our studies
must address communications in a larger sense, must
encompass all the settings in which an “episode of
care” occurs, and must focus on patient outcomes and
use of resources. The measured end points of an intervention should of course be sensitive to the particular
setting where the intervention takes place, or else
small and location-specific gains will be missed. However, real health effects and robust measures of efficiency must take the place of word counts, inclusion
checklists, and clinician adoption or satisfaction in the
design of documentation studies.
A great national experiment is underway involving
the deployment of information technology, the expansion and empowerment of healthcare teams, and the
retargeting of economic incentives. The experimental
hypothesis is that technology will increase medical
efficiency and will benefit patient well-being only if
these are in fact the purposes, and if teamwork is the
principal means, of providing medical care. We should
seize this time of change as an opportunity to measure
and demonstrably improve the contribution of medical documentation and communication to the efficient
and long-term remission of disease.
References
1. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;
278(12):593–600.
2. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;
278(12):652–257.
3. Hripcsak G, Vawdrey DK, Fred MR, Bostwick SB. Use of electronic
clinical documentation: time spent and team interactions. J Am Med
Inform Assoc. 2011;18(2):112–117.
4. Yee T, Needleman J, Pearson M, Parkerton P, Parkerton M, Wolstein J.
The influence of integrated electronic medical records and computerized
nursing notes on nurses’ time spent in documentation. Comput Inform
Nurs. 2012;30(6):287–292.
5. Kargul GJ, Wright SM, Knight AM, McNichol MT, Riggio JM. The
hybrid progress note: semiautomating daily progress notes to achieve
high-quality documentation and improve provider efficiency. Am J
Med Qual. 2013;28(1):25–32.
6. Stetson PD, Morrison FP, Bakken S, Johnson SB. Preliminary development of the physician documentation quality instrument. J Am Med
Inform Assoc. 2008;15(4):534–541.
7. Deering S, Poggi S, Hodor J, Macedonia C, Satin AJ. Evaluation of
residents’ delivery notes after a simulated shoulder dystocia. Obstet
Gynecol. 2004;104(4):667–670.
8. Park YS, Lineberry M, Hyderi A, Bordage G, Riddle J, Yudkowsky R.
Validity evidence for a patient note scoring rubric based on the new
patient note format of the United States Medical Licensing Examination. Acad Med. 2013;88(10):1552–1557.
Journal of Hospital Medicine Vol 00 | No 00 | Month 2013
ID: komathi.k Time: 12:29 I Path: N:/3b2/JHM#/Vol00000/130100/APPFile/JW-JHM#130100
J_ID: JHM Customer A_ID: JHM2104 Cadmus Art: JHM2104 Ed. Ref. No.: 13-0322.R2 Date: 18-October-13
Stage:
Page: 3
Studying Documentation
9. Hanson JL, Stephens MB, Pangaro LN, Gimbel RW. Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research. BMC Health Serv Res. 2012;12:407.
10. Hayrinen K, Saranto K, Nykanen P. Definition, structure, content, use
and impacts of electronic health records: a review of the research literature. Int J Med Inform. 2008;77(5):291–304.
11. Grigg E, Palmer A, Grigg J, et al. Randomised trial comparing the
recording ability of a novel, electronic emergency documentation system with the AHA paper cardiac arrest record [published online ahead
of print July 29, 2013]. Emerg Med J. doi: 10.1136/emermed-2013202512.
12. Rosenbloom ST, Stead WW, Denny JC, et al. Generating clinical notes
for electronic health record systems. Appl Clin Inform. 2010;1(3):
232–243.
13. Park SY, Lee SY, Chen Y. The effects of EMR deployment on doctors’
work practices: a qualitative study in the emergency department of a
teaching hospital. Int J Med Inform. 2012;81(3):204–217.
An Official Publication of the Society of Hospital Medicine
|
Shine
14. Stengel D, Bauwens K, Walter M, Kopfer T, Ekkernkamp A. Comparison of handheld computer-assisted and conventional paper chart documentation of medical records. A randomized, controlled trial. J Bone
Joint Surg Am. 2004;86A(3):553–560.
15. Rao P, Andrei A, Fried A, Gonzalez D, Shine D. Assessing quality and
efficiency of discharge summaries. Am J Med Qual. 2005;20(6):
337–343.
16. O’Donnell HC, Kaushal R, Barron Y, Callahan MA, Adelman
RD, Siegler EL. Physicians’ attitudes towards copy and pasting
in electronic note writing. J Gen Intern Med. 2009;24(1):
63–68.
17. Shoolin J, Ozeran L, Hamann C, Bria Ii W. Association of medical
directors of information systems consensus on inpatient electronic
health record documentation. Appl Clin Inform. 2013;4(2):293–303.
18. Linder JA, Schnipper JL, Middleton BJ. Method of electronic health
record documentation and quality of primary care. Am Med Inform
Assoc. 2012;19(6):1019–1024.
Journal of Hospital Medicine Vol 00 | No 00 | Month 2013
ID: komathi.k Time: 12:29 I Path: N:/3b2/JHM#/Vol00000/130100/APPFile/JW-JHM#130100
3
J_ID: JHM Customer A_ID: JHM2104 Cadmus Art: JHM2104 Ed. Ref. No.: 13-0322.R2 Date: 18-October-13
AQ1 Please provide the corresponding author’s fax number.
View publication stats
ID: komathi.k Time: 12:29 I Path: N:/3b2/JHM#/Vol00000/130100/APPFile/JW-JHM#130100
Stage:
Page: 4
Download