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Studying Documentation
Article in Journal of Hospital Medicine · December 2013
DOI: 10.1002/jhm.2104 · Source: PubMed
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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.
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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
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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.
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Shine
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